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Nepal
Demographic and
Health Survey


World Summit for Children Indicators, Nepal 2001

Childhood mortality


Childhood undernutrition



Clean water supply

Sanitary excreta disposal

Basic education



Family planning

Antenatal care

Delivery care

Vitamin A supplements


Night blindness

Exclusive breastfeeding

Continued breastfeeding


Timely complementary feeding

Vaccinations





Diarrhea control


Home management of diarrhea


Acute respiratory infection


Home management of illness


HIV/AIDS
Infant mortality rate (per 1,000 live births)
Under-five mortality rate (per 1,000 live births)

Percent stunted (children under 5 years)

Percent wasted (children under 5 years)


Percent underweight (children under 5 years)



Percent of households within 15 minutes of safe water supply
1


Percent of households with flush toilets, pit toilet/latrine

Proportion of children reaching grade 5
2

Net primary-school attendance rate
2

Proportion of children entering primary school
2


Contraceptive prevalence rate (any method, currently married women)

Percent of women who received antenatal care from a health professional
3


Percent of births in the 5 years preceding the survey attended by a health professional

Percent of children age 6-59 months

who received a vitamin A dose in the 6 months preceding the
survey
Percent of women age 15-49 who received a vitamin A dose in the 2 months after delivery
3

Percent of women age 15-49 who suffered from night blindness during pregnancy
3,4


Percent of children under 4 months who are exclusively breastfed

Percent of all children age 12-15 months still breastfeeding

Percent of all children age 20-23 months still breastfeeding

Percent of children age 6-9 months receiving breast milk and complementary foods

Percent of children age 12-23 months with BCG vaccination
Percent of children age 12-23 months with at least 3 DPT vaccinations
Percent of children age 12-23 months with at least 3 polio vaccinations
Percent of children age 12-23 months with measles vaccination
Percent of children whose mother received at least 2 tetanus toxoid vaccinations during pregnancy
3

Percent of children age 0-59 months with diarrhea in the 2 weeks preceding the survey who received
oral
rehydration salts (ORS)

Percent of children age 0-59 months with diarrhea in the 2 weeks preceding the interview
who took more fluids than usual and continued eating somewhat less, the same, or more food

Percent of children age 0-59 months with acute respiratory infection (ARI) in the 2 weeks preceding
the
survey who were taken to a health provider

Percent of children age 0-59 months with diarrhea, fever, and/or ARI who were taken to a health
provider

Percent of women age 15-49 who correctly state two ways of avoiding HIV infection
5

Percent of women age 15-49 who believe that AIDS can be transmitted from mother to child

64.4
91.2

50.5
9.6
48.3

78.3

30.4

91.5
73.0
41.0

39.3

48.5

12.9

81.0
10.3

19.6

78.8

98.1
87.3

66.2

84.5
72.1
91.5
70.6
45.3


32.2


24.5


26.1


22.6

31.3
41.2
1
Piped water or protected well water

2
Based on de jure children
3
For the last live birth in the five years preceding the survey
4
Includes women who report night blindness and difficulty with vision during the day
5
Having sex with only one partner who has no other partners and using a condom every time they have sex

Nepal
Demographic and
Health Survey
2001





Family Health Division
Department of Health Services
Ministry of Health
His Majestys Government
Kathmandu, Nepal

New ERA
Kathmandu, Nepal

ORC Macro
Calverton, Maryland USA


April 2002










Ministry of Health New ERA ORC Macro








































The 2001 Nepal Demographic and Health Survey (NDHS) was implemented by New ERA under the aegis
of the Family Health Division, Department of Health Services, Ministry of Health. ORC Macro provided technical
assistance through its MEASURE DHS+ program. The survey was funded by the U.S. Agency for International
Development (USAID under the terms of Contract No. HRN-C-00-97-0019-00).

The 2001 Nepal Demographic and Health Survey is part of the worldwide Demographic and Health
Surveys (DHS) program. Additional information about the 2001 NDHS may be obtained from the Family Health
Division, Department of Health Services, Ministry of Health, P.O. Box 820, Teku, Kathmandu, Nepal (telephone:
262155; fax: 262238) and New ERA, Rudramati Marg, Kalopul, P.O. Box 722, Kathmandu, Nepal (telephone:
413603 or 423176; fax: 419562; email: info@newera.wlink.np). Information about the MEASURE DHS+ project
may be obtained from ORC Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-
0200; fax: 301-572-0999; email: reports@macroint.com; internet: www.measuredhs.com).

Suggested citation:

Ministry of Health [Nepal], New ERA, and ORC Macro. 2002. Nepal Demographic and Health Survey 2001.
Calverton, Maryland, USA: Family Health Division, Ministry of Health; New ERA; and ORC Macro.
Contents * iii
CONTENTS



Page

Tables and Figures .............................................................................................................................. vii
Foreword............................................................................................................................................ xiii
Acknowledgments................................................................................................................................xv
2001 NDHS Technical Advisory Committee ................................................................................... xvii
Contributors to the Report ................................................................................................................. xix
Summary of Findings......................................................................................................................... xxi
Map of Nepal ................................................................................................................................. xxviii

CHAPTER 1 INTRODUCTION............................................................................................ 1

1.1 Geography and Economy............................................................................................1
1.2 Population ...................................................................................................................2
1.3 Population and Reproductive Health Policies and Programs .....................................3
1.4 Objectives and Organization of 2001 NDHS Survey .................................................5

CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS............... 9

2.1 Age and Sex Composition of the Household Population............................................9
2.2 Household Composition............................................................................................12
2.3 Education of Household Members............................................................................13
2.4 Housing Characteristics ............................................................................................19

CHAPTER 3 RESPONDENTS CHARACTERISTICS AND STATUS .................................... 23

3.1 Background Characteristics of Respondents ............................................................23
3.2 Educational Attainment by Background Characteristics ..........................................25
3.3 Literacy .....................................................................................................................27
3.4 Exposure to Mass Media...........................................................................................30
3.5 Employment Status ...................................................................................................33
3.6 Occupation................................................................................................................36
3.7 Type of Employment ................................................................................................39
3.8 Decision on Use of Earnings.....................................................................................41
3.9 Womens Empowerment and Status.........................................................................44
3.10 Smoking and Alcohol Consumption.........................................................................53
iv * Contents
Page
CHAPTER 4 FERTILITY ..................................................................................................... 55

4.1 Current Fertility ........................................................................................................55
4.2 Pregnancy Outcomes ...............................................................................................59
4.3 Children Ever Born and Living.................................................................................60
4.4 Birth Intervals ...........................................................................................................61
4.5 Age at First Birth ......................................................................................................63
4.6 Adolescent Fertility...................................................................................................65

CHAPTER 5 FAMILY PLANNING ...................................................................................... 67

5.1 Knowledge of Contraceptive Methods .....................................................................67
5.2 Ever Use of Contraception........................................................................................68
5.3 Current Use of Contraception ..................................................................................69
5.4 Current Use of Contraception by Background Characteristics.................................71
5.5 Trends in Current Use of Family Planning...............................................................74
5.6 Current Use of Contraception by Womens Status...................................................76
5.7 Number of Children at First Use of Contraception...................................................78
5.8 Knowledge of Fertile Period.....................................................................................78
5.9 Sterilization...............................................................................................................79
5.10 Condom Use..............................................................................................................82
5.11 Mens Attitudes toward Contraception.....................................................................82
5.12 Source of Contraception ...........................................................................................85
5.13 Time Taken to Reach Source of Contraception........................................................87
5.14 Informed Choice .......................................................................................................88
5.15 Future Use of Contraception.....................................................................................90
5.16 Reasons for Nonuse of Contraception ......................................................................91
5.17 Preferred Method of Contraception for Future Use..................................................92
5.18 Exposure to Family Planning Messages ...................................................................93
5.19 Exposure to Specific Radio Shows on Family Planning ..........................................95
5.20 Contact of Nonusers with Family Planning Providers..............................................97
5.21 Discussion of Family Planning Between Spouses....................................................99

CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY................................ 101

6.1 Current Marital Status.............................................................................................101
6.2 Polygyny .................................................................................................................103
6.3 Age at First Marriage..............................................................................................105
6.4 Age at First Sexual Intercourse...............................................................................105
6.5 Recent Sexual Activity ...........................................................................................107
6.6 Postpartum Insusceptibility ....................................................................................110
6.7 Termination of Exposure to Pregnancy ..................................................................113
Contents * v

Page
CHAPTER 7 FERTILITY PREFERENCES............................................................................ 115

7.1 Desire for More Children........................................................................................115
7.2 Desire to Limit Childbearing by Background Characteristics................................117
7.3 Need for Family Planning Services ........................................................................119
7.4 Ideal Family Size ....................................................................................................121
7.5 Fertility Planning ....................................................................................................123

CHAPTER 8 INFANT AND CHILD MORTALITY.............................................................. 127

8.1 Data Quality............................................................................................................127
8.2 Levels and Trends in Infant and Child Mortality....................................................128
8.3 Socioeconomic Differentials in Mortality ..............................................................130
8.4 Demographic Differentials in Mortality .................................................................132
8.5 Womens Status and Child Mortality .....................................................................134
8.6 Perinatal Mortality ..................................................................................................134
8.7 High-Risk Fertility Behavior ..................................................................................136

CHAPTER 9 MATERNAL AND CHILD HEALTH.............................................................. 139

9.1 Antenatal Care ........................................................................................................139
9.2 Delivery Care..........................................................................................................147
9.3 Postnatal Care .........................................................................................................153
9.4 Reproductive Health Care and Womens Status.....................................................153
9.5 Vaccination of Children..........................................................................................155
9.6 Prevalence and Treatment of ARI and Fever..........................................................159
9.7 Diarrhea...................................................................................................................161
9.8 Womens Status and Use of Health Services..........................................................167
9.9 Womens Perceptions of Problems in Accessing Health Care ...............................168
9.10 Use of Smoking Tobacco .......................................................................................168

CHAPTER 10 INFANT FEEDING AND CHILDRENS AND WOMENS
NUTRITIONAL STATUS.............................................................................. 171

10.1 Initiation of Breastfeeding ......................................................................................171
10.2 Breastfeeding Status by Age of the Child...............................................................173
10.3 Duration and Frequency of Breastfeeding..............................................................175
10.4 Types of Complementary Foods.............................................................................177
10.5 Frequency of Food Supplementation......................................................................178
10.6 Micronutrient Intake ...............................................................................................181
10.7 Nutritional Status of Children.................................................................................185
10.8 Nutritional Status of Women ..................................................................................191
vi * Contents
Page
CHAPTER 11 KNOWLEDGE OF HIV/AIDS ....................................................................... 195

11.1 Knowledge of HIV/AIDS .......................................................................................196
11.2 Knowledge of HIV/AIDS Prevention.....................................................................196
11.3 Knowledge of HIV/AIDS-Related Issues...............................................................200
11.4 Spousal Communication about HIV/AIDS.............................................................200
11.5 Sexual Behavior ......................................................................................................203
11.6 Knowledge and Use of Condoms ...........................................................................203

REFERENCES .................................................................................................................... 209

APPENDIX A SAMPLE DESIGN......................................................................................... 211

APPENDIX B SAMPLING ERRORS.................................................................................... 221

APPENDIX C DATA QUALITY TABLES ............................................................................. 229

APPENDIX D SURVEY STAFF ............................................................................................ 235

APPENDIX E QUESTIONNAIRES ...............................................................................................239

Tables and Figures * vii
TABLES AND FIGURES


Page
CHAPTER 1 INTRODUCTION

Table 1.1 Basic demographic indicators........................................................................................3
Table 1.2 Results of the household and individual interviews ......................................................7

CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS

Table 2.1 Household population by age, sex, and residence .......................................................11
Table 2.2 Household composition ...............................................................................................12
Table 2.3.1 Educational attainment of household population: male..............................................14
Table 2.3.2 Educational attainment of household population: female...........................................15
Table 2.4 School attendance ratios ..............................................................................................17
Table 2.5 Grade repetition and dropout rates...............................................................................18
Table 2.6 Housing characteristics ................................................................................................20
Table 2.7 Household durable goods.............................................................................................21

Figure 2.1 Distribution of de facto household population by single year of age and sex.............10
Figure 2.2 Population pyramid, Nepal, 2001 ................................................................................12
Figure 2.3 Age-specific school attendance rates ...........................................................................19

CHAPTER 3 RESPONDENTS CHARACTERISTICS AND STATUS

Table 3.1 Background characteristics of respondents..................................................................24
Table 3.2.1 Educational attainment of women ...............................................................................25
Table 3.2.2 Educational attainment of men ....................................................................................26
Table 3.3.1 Literacy of women.......................................................................................................28
Table 3.3.2 Literacy of men............................................................................................................29
Table 3.4.1 Exposure to mass media: women.................................................................................31
Table 3.4.2 Exposure to mass media: men......................................................................................32
Table 3.5.1 Employment status: women.........................................................................................34
Table 3.5.2 Employment status: men..............................................................................................35
Table 3.6.1 Occupation: women .....................................................................................................37
Table 3.6.2 Occupation: men..........................................................................................................38
Table 3.7.1 Type of employment: women ......................................................................................39
Table 3.7.2 Type of employment: men...........................................................................................40
Table 3.8 Decision on use of earnings .........................................................................................42
Table 3.9 Contribution of earnings to household expenditures ...................................................43
Table 3.10 Womens control over earnings...................................................................................44
Table 3.11 Womens participation in decisionmaking ..................................................................45
Table 3.12 Womens participation in decisionmaking by background characteristics..................46
Table 3.13.1 Womens attitude toward wife beating........................................................................48
viii * Tables and Figures
Page

Table 3.13.2 Mens attitude toward wife beating .............................................................................49
Table 3.14.1 Womens attitude toward refusing sex with husband..................................................51
Table 3.14.2 Mens attitude toward refusing sex with husband .......................................................52
Table 3.15 Smoking and alcohol consumption..............................................................................54

Figure 3.1 Employment status of women age 15-49.....................................................................36
Figure 3.2 Type of earnings of employed women age 15-49........................................................40
Figure 3.3 Distribution of women by number of decisions in which they participate..................47

CHAPTER 4 FERTILITY

Table 4.1 Current fertility ............................................................................................................56
Table 4.2 Fertility by background characteristics........................................................................57
Table 4.3 Trends in fertility .........................................................................................................58
Table 4.4 Trends in age-specific fertility rates ............................................................................59
Table 4.5 Pregnancy outcome......................................................................................................60
Table 4.6 Children ever born and living ......................................................................................61
Table 4.7 Birth intervals...............................................................................................................62
Table 4.8 Age at first birth...........................................................................................................63
Table 4.9 Median age at first birth...............................................................................................64
Table 4.10 Teenage pregnancy and motherhood ...........................................................................65

Figure 4.1 Trends in total fertility rate 1984-2001........................................................................58

CHAPTER 5 FAMILY PLANNING

Table 5.1 Knowledge of contraceptive methods..........................................................................68
Table 5.2 Ever use of contraception.............................................................................................69
Table 5.3 Current use of contraception........................................................................................70
Table 5.4.1 Current use of contraception by background characteristics: women .........................72
Table 5.4.2 Current use of contraception by background characteristics: men..............................73
Table 5.5 Trends in current use of modern contraceptive methods .............................................75
Table 5.6 Current use of contraception by womens status .........................................................77
Table 5.7 Number of children at first use of contraception .........................................................78
Table 5.8 Knowledge of fertile period.........................................................................................79
Table 5.9 Timing of female sterilization......................................................................................80
Table 5.10 Sterilization regret........................................................................................................81
Table 5.11 Mens attitudes toward contraception and gender roles ..............................................83
Table 5.12 Mens attitudes toward injectables...............................................................................84
Table 5.13 Mens attitudes toward female sterilization.................................................................85
Table 5.14 Source of contraception ...............................................................................................86
Table 5.15 Time taken to reach source of contraception ...............................................................87
Table 5.16 Informed choice ...........................................................................................................89
Table 5.17 Future use of contraception..........................................................................................90
Table 5.18 Reason for not intending to use contraception.............................................................91
Tables and Figures * ix
Page

Table 5.19 Preferred method of contraception for future use........................................................92
Table 5.20 Exposure to family planning messages........................................................................94
Table 5.21 Exposure to specific radio shows on family planning .................................................96
Table 5.22 Contact of nonusers with family planning providers...................................................98
Table 5.23 Discussion of family planning with spouse .................................................................99
Table 5.24 Decision on use of contraception...............................................................................100
Table 5.25 Wifes perception of husbands attitude toward family planning..............................100

Figure 5.1 Trends in current use of modern contraceptive methods among currently
married non-pregnant women age 15-49, Nepal, 1976-2001 ......................................76

CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY

Table 6.1 Current marital status.................................................................................................102
Table 6.2 Trends in proportion never married...........................................................................103
Table 6.3 Polygyny ....................................................................................................................104
Table 6.4 Median age at marriage and median age at first sexual intercourse ..........................106
Table 6.5 Recent sexual activity: women ..................................................................................108
Table 6.6 Recent sexual activity: men .......................................................................................109
Table 6.7 Postpartum amenorrhea, abstinence and insusceptibility ..........................................111
Table 6.8 Median duration of postpartum insusceptibility by background characteristics .......112
Table 6.9 Menopause .................................................................................................................113

CHAPTER 7 FERTILITY PREFERENCES

Table 7.1 Fertility preferences by number of living children ....................................................116
Table 7.2 Desire for more children among monogamous couples ............................................117
Table 7.3 Desire to limit childbearing .......................................................................................118
Table 7.4 Need for family planning...........................................................................................120
Table 7.5 Ideal number of children............................................................................................122
Table 7.6 Mean ideal number of children by background characteristics .................................123
Table 7.7 Fertility planning status..............................................................................................124
Table 7.8 Wanted fertility rates..................................................................................................125
Table 7.9 Ideal number of children and unmet need for family planning by womens status...126

CHAPTER 8 INFANT AND CHILD MORTALITY

Table 8.1 Early childhood mortality rates..................................................................................129
Table 8.2 Trends in infant mortality ..........................................................................................129
Table 8.3 Early childhood mortality rates by socioeconomic characteristics............................131
Table 8.4 Early childhood mortality rates by demographic characteristics...............................132
Table 8.5 Early childhood mortality rates by womens status...................................................134
Table 8.6 Perinatal mortality......................................................................................................136
Table 8.7 High-risk fertility behavior ........................................................................................137
x * Tables and Figures
Page

Figure 8.1 Trends in infant mortality, Nepal, 1969-2001 ...........................................................130
Figure 8.2 Under-five mortality rates by place of residence.......................................................131
Figure 8.3 Under-five mortality by selected demographic characteristics..................................133

CHAPTER 9 MATERNAL AND CHILD HEALTH

Table 9.1 Antenatal care ............................................................................................................140
Table 9.2 Number of antenatal care visits and timing of first visit............................................142
Table 9.3 Components of antenatal care....................................................................................144
Table 9.4 Tetanus toxoid injections ...........................................................................................146
Table 9.5 Place of delivery ........................................................................................................148
Table 9.6 Assistance during delivery.........................................................................................150
Table 9.7 Use of clean home delivery kits.................................................................................151
Table 9.8 Delivery characteristics..............................................................................................152
Table 9.9 Postnatal care by background characteristics ............................................................154
Table 9.10 Reproductive health care by womens status.............................................................155
Table 9.11 Vaccinations by source of information......................................................................156
Table 9.12 Vaccinations by background characteristics..............................................................158
Table 9.13 Prevalence and treatment of symptoms of ARI and fever .........................................160
Table 9.14 Disposal of childs stools...........................................................................................162
Table 9.15 Prevalence of diarrhea................................................................................................163
Table 9.16 Knowledge of ORS packets .......................................................................................164
Table 9.17 Diarrhea treatment .....................................................................................................165
Table 9.18 Feeding practices during diarrhea..............................................................................166
Table 9.19 Child health care by womens status .........................................................................167
Table 9.20 Problems in accessing health care..............................................................................169
Table 9.21 Use of smoking tobacco.............................................................................................170

Figure 9.1 Antenatal care, tetanus toxoid (TT) vaccinations, place of delivery, and
delivery assistance .....................................................................................................141
Figure 9.2 Percentage of children age 12-23 months who received specific vaccinations
by 12 months of age, 1996 and 2001.........................................................................157


CHAPTER 10 INFANT FEEDING AND CHILDRENS AND WOMENS
NUTRITIONAL STATUS

Table 10.1 Initial breastfeeding ...................................................................................................172
Table 10.2 Breastfeeding status by age........................................................................................174
Table 10.3 Median duration and frequency of breastfeeding ......................................................176
Table 10.4 Foods consumed by children in the day or night preceding the interview................177
Table 10.5 Frequency of foods consumed by children in the day or night preceding
the interview...............................................................................................................179
Table 10.6 Frequency of foods consumed by children in preceding seven days.........................180
Table 10.7 Vitamin A intake among children..............................................................................182
Table 10.8 Vitamin A supplemnt .................................................................................................184
Tables and Figures * xi
Page

Table 10.9 Micronutrient intake among mothers.........................................................................186
Table 10.10 Nutritional status of children .....................................................................................188
Table 10.11 Trends in nutritional status of children......................................................................191
Table 10.12 Nutritional status of women by background characteristics ......................................192

Figure 10.1 Number of meals consumed per day by children under 36 months living
with the mother ..........................................................................................................181
Figure 10.2 Nutritional status of children by age..........................................................................190

CHAPTER 11 KNOWLEDGE OF HIV/AIDS

Table 11.1 Knowledge of AIDS ..................................................................................................197
Table 11.2 Knowledge of ways to avoid HIV/AIDS...................................................................198
Table 11.3 Knowledge of programmatically important ways to avoid HIV/AIDS.....................199
Table 11.4 Knowledge of HIV/AIDS-related issues ...................................................................201
Table 11.5 Discussionof HIV/AIDS with spouse ........................................................................202
Table 11.6 Number of sexual partners.........................................................................................204
Table 11.7 Knowledge of source of condoms, and access to condoms .......................................205
Table 11.8 Use of condoms by type of partner ............................................................................207


APPENDIX A SAMPLE DESIGN

Table A.1 Sample allocation.......................................................................................................213
Table A.2.1 Sample implementation: women................................................................................218
Table A.2.2 Sample implementation: men ....................................................................................219


APPENDIX B SAMPLING ERRORS

Table B.1 List of selected variables for sampling errors, Nepal 2001 .......................................224
Table B.2 Sampling errors - Total sample, Nepal 2001 .............................................................225
Table B.3 Sampling errors - Urban sample, Nepal 2001............................................................226
Table B.4 Sampling errors - Rural sample, Nepal 2001.............................................................227


APPENDIX C DATA QUALITY TABLES

Table C.1 Household age distribution ........................................................................................229
Table C.2.1 Age distribution of eligible and interviewed women.................................................230
Table C.2.2 Age distribution of eligible and interviewed men......................................................230
Table C.3 Completeness of reporting.........................................................................................231
Table C.4 Births by calendar years.............................................................................................232
Table C.5 Reporting of age at death in days...............................................................................233
Table C.6 Reporting of age at death in months ..........................................................................234
Foreword * xiii
FOREWORD


Periodic demographic and health surveys have supplemented and complemented censuses.
The Nepal Fertility Survey 1976 (a part of the World Fertility Survey) was the first nationally repre-
sentative demographic and health survey conducted in Nepal. Since then, the Department of Health,
Ministry of Health, has conducted several similar surveys at intervals of five years. The 2001 Nepal
Demographic and Health Survey (NDHS) is the sixth such survey and the second survey conducted
as part of the worldwide Demographic and Health Surveys (DHS) program. These types of surveys
will continue to be the main sources of demographic estimates until the registration of all vital events
are reported correctly and in a timely fashion.

The 2001 Nepal Demographic and Health Survey (NDHS) is the sixth in a series of demo-
graphic surveys. The 2001 NDHS was conducted under the aegis of the Family Health Division and
was implemented by New ERA. Technical support was provided by ORC Macro, and financial sup-
port was provided by the United States Agency for International Development.

The 2001 NDHS included important areas such as maternal and child health; perinatal, neona-
tal, infant, and child mortality; knowledge of HIV/AIDS; family planning knowledge and use; fertil-
ity; fertility preference; marriage; abortion; amenorrhea; and status of women. This information is
important in understanding the issues related to population and health and is at the same time instru-
mental to monitoring and evaluating population and health programs. The wealth of information ob-
tained from the 2001 NDHS will also help in formulating short- and long-term plans. The govern-
ment of Nepal is in the process of formulating the Tenth (five-year) Development Plan, and it should
be of immense satisfaction to all that the information obtained form this survey is being used in the
formulation of the plan.

It is immensely satisfying to acknowledge that the 2001 NDHS has been successfully com-
pleted on time despite the heightened security concerns when the survey was in the field. It is not
only important to complete such surveys on time, but it is also important to ensure that the data is of
good quality. It is assuring to note that every effort was made to obtain correct data and ensure its
quality. I believe that the information obtained from this survey will help in the formulation of pro-
grams for family planning, safe motherhood, HIV/AIDS, and child health and survival for the Tenth
Development Plan.

I deeply appreciate the United States Agency for International Development for providing the
financial support for the 2001 NDHS and ORC Macro for providing valuable technical assistance. I
express my gratitude to Dr. B. D. Chataut, my predecessor, for chairing the Technical Advisory
Committee for the 2001 NDHS. I appreciate New ERA and its staff for supervising the fieldwork and
data entry. My sincere thanks go to Mr. Ajit Pradhan, Senior Demographer and Member Secretary to
the 2001 NDHS Technical Advisory Committee, and Mr. Bharat Ban, Executive Director, New ERA,
for their dedication in the successful completion of the 2001 NDHS. Last but not least, I highly ap-
preciate the technical input provided by the members of the 2001 NDHS Technical Advisory Com-
mittee.

Dr. Laxmi Raj Pathak
Director General
Department of Health Services
Ministry of Health
His Majesty's Government
Teku, Kathmandu, Nepal
Acknowledgments * xv
ACKNOWLEDGMENTS


This study is the outcome of the dedicated efforts of many institutions and individuals. The
2001 Nepal Demographic and Health Survey (NDHS) was conducted under the aegis of the Family
Health Division, Department of Health Services, Ministry of Health of His Majestys Government of
Nepal. The 2001 NDHS was funded by the United States Agency for International Development
(USAID) through its mission in Nepal and was implemented by New ERA, a local research firm.
ORC Macro provided technical support for the survey.

We would like to thank Ms. Anjushree Pradhan, Deputy Project Director; Dr. Gokarna
Regmi, Technical Advisor; Mr. Matrika Chapagain, Research Officer; Mr. Muneshor Shrestha and
Mr. Pushpa Basnet, research assistants; Ms. Sarita Vaidya and Mr. Rajendra Lal Singh, data process-
ing staff; Mr. Sanu Raja Shakya, word processing staff; and other field and data entry staff of New
ERA who made significant contributions to the successful completion of this study.

A number of persons from various institutions contributed to the preparation of this report.
Their contribution is highly acknowledged.

Our sincere gratitude goes to all the members of the Technical Advisory Committee for the
2001 NDHS, for their time, support, and valuable feedback.

Our deep appreciation also goes to the USAID mission in Nepal. We would like to express
our sincere gratitude to Ms. Rebecca Rohrer, Chief, Office of Health and Family Planning, and
Mr. Terence Murphy, Reproductive Health Advisor, for their keen interest and active support
throughout this survey. We also acknowledge the valuable inputs of Mr. Lyndon Brown, Technical
Advisor for Child Health and Nutrition; Ms. Anne Peniston, Technical Advisor for Health and Fam-
ily Planning; Ms. Cathy Thompson, Technical Advisor for HIV/AIDS; and Mrs. Pancha Kumari
Manandhar, Family Planning Program Specialist.

The technical support provided by ORC Macro is highly acknowledged. Our special thanks
go to Dr. Pav Govindasamy, the country manager for Nepal, for her effort and contribution through-
out the survey. We also wish to thank Ms. Anne Cross, regional coordinator; Dr. Alfredo Aliaga,
sampling expert; Mr. Guillermo Rojas, data processing specialist; and Ms. Livia Montana, geo-
graphic information specialist.

We greatly appreciate the support from various institutions in implementing the survey. We
would especially like to thank the support provided by officials of the District Health Offices, Dis-
trict Administrative Offices, District Police Offices, Health Posts, Sub-health Posts, Village Devel-
opment Committees, non-governmental organizations, and other individuals.

The survey was conducted in an extremely difficult field environment and our gratitude goes
to the supervisors, field editors, interviewers, and members of the quality control teams whose dedi-
cated efforts made completing the survey possible. We would also like to thank all the respondents
for their time and patience during the interview. We believe that this study has truly captured the
facts related to the demographic and health situation in Nepal. We also hope that this information
will help in improving the quality of life of the Nepalese people.

Bharat Ban Ajit Pradhan
Executive Director Senior Demographer
New ERA Family Health Division
2001 NDHS Technical Advisory Committee * xvii
2001 NDHS TECHNICAL ADVISORY COMMITTEE


Dr. Laxmi Raj Pathak, Director General, Department of Health Services, Ministry of Health
Dr. B. D. Chataut, former Director General, Department of Health Services, Ministry of Health
Mr. Ram Krishna Tiwari, Joint Secretary, National Planning Commission Secretariat
Dr. Bimala Ojha, former Director, National Center for AIDS and STD Control
Mr. Laxmi Raman Ban, former Director, National Health Education Information and
Communication Center
Dr. Ram Hari Aryal, Joint Secretary, Parliament Secretariat
Mr. Badri Niroula, Deputy Director, Central Bureau of Statistics
Representative, National Health Research Council
Dr. Ram Sharan Pathak, Associate Professor, Central Department of Population Studies, Tribhuvan
University
Mr. Terence Murphy, Reproductive Health Advisor, USAID/Nepal
Dr. Shyam Thapa, Senior Scientist, Family Health International
Mr. Tek Bahadur Dangi, Senior Public Health Administrator, Management Division, Ministry of
Health
Mr. Munishwor Mool, Senior Public Health Administrator, Management Division, Ministry of
Health
Dr. Son Lal Thapa, CDD/ARI Chief, Child Health Division, Ministry of Health
Mr. Upendra Adhikary, Under Secretary, Ministry of Population and Environment
Mr. Ajit Pradhan, Senior Demographer, Family Health Division, Ministry of Health
Mr. Bharat Ban, Executive Director, New ERA
Dr. Pav Govindasamy, Country Manager, ORC Macro
Contributors to the Report * xix
CONTRIBUTORS TO THE REPORT


The following persons contributed to the preparation of this report:

Mr. Munishwor Mool, Management Division, Ministry of Health
Mr. Ajit Pradhan, Family Health Division, Ministry of Health
Dr. Ram Sharan Pathak, Central Department of Population Studies, Tribhuvan University
Mr. Upendra Adhikary, Ministry of Population and Environment
Mr. Bharat Ban, New ERA
Dr. Gokarna Regmi, New ERA
Ms. Anjushree Pradhan, New ERA
Dr. Pav Govindasamy, ORC Macro
Dr. Alfredo Aliaga, ORC Macro
Summary of Findings * xxi
SUMMARY OF FINDINGS


The 2001 Nepal Demographic and Health Sur-
vey (NDHS) is a nationally representative sur-
vey of 8,726 women age 15-49 and 2,261 men
age 15-59. This survey is the sixth in a series of
national-level population and health surveys
and the second comprehensive survey con-
ducted as part of the global Demographic and
Health Surveys (DHS) program, the first being
the 1996 Nepal Family Health Survey (NFHS).
The primary purpose of the NDHS is to gener-
ate recent and reliable information on fertility,
family planning, infant and child mortality, ma-
ternal and child health, and nutrition. In addi-
tion, the survey collected information on
knowledge of HIV/AIDS.

FERTILITY

Comparison of data from the 2001 NDHS with
earlier surveys conducted in Nepal indicates that
fertility has declined steadily from 5.1 births per
woman in 1984-1986 to 4.1 births per woman in
1998-2000. Further evidence of recent fertility
decline is obtained from the pregnancy history
information collected in the 2001 NDHS. There
has been an 18 percent decline in fertility among
women below age 30, from 3.6 births per woman
during the period 15-19 years before the survey
to 2.9 births per woman during the period 0-4
years before the survey, with the largest decline
in fertility (14 percent) occurring between 5-9
and 0-4 years before the survey. Differences by
place of residence are marked, with rural women
having more than twice as many children (4.4) as
urban women (2.1). Fertility is highest in the
mountains (4.8 births per woman), with little dif-
ference in fertility between the hills (4.0 births
per woman) and the terai (4.1 births per woman).
Education is strongly related to fertility, with un-
educated women having more than twice as
many children (4.8) as women with at least some
secondary education (2.3).

Data from the national censuses and the 2001
NDHS indicate that the proportion never married
among women and men below age 25 has in-
creased gradually over time. Only one in four

women age 15-19 was not married in 1961,
compared with three in five women in 2001.
Similarly in 1961, 5 percent of women age 20-24
had never married, compared with more than
three times as many in the same age group five
decades later. A similar pattern of decline in
nuptiality is observed among men as well, with a
proportionately larger change again observed
among the youngest age group.

These trends result in a small but noticeable in-
crease in age at marriage. The median age at
marriage has risen slowly over the last two dec-
ades, from 16.1 years for women age 45-49 to
16.8 years among women age 20-24. Data also
show a small change in the median age at mar-
riage among males, with men marrying about
three years later than women.

Overall, the median age at first sexual inter-
course among Nepalese women in the reproduc-
tive age group is nearly identical to their median
age at first marriage, implying that womens first
sexual experience usually occurs within the con-
text of marriage. However, there is little differ-
ence in the median age at first sexual intercourse
among women by age, implying that there has
been little change in the median age at first sex-
ual intercourse over the years. Women generally
have their first sexual experience two years ear-
lier than men. However, men tend to initiate sex
about one year before marriage.

The median age at first birth is about 20
years across all age cohorts, indicating virtually
no change in the age at first birth over the last
two decades. At least 70 percent of women in all
age cohorts had their first birth by age 22, with
the proportion of women having their first birth
by age 22 declining with increasing age of the
mother. About 90 percent of Nepalese women
have their first birth by age 25. One in five ado-
lescent women age 15-19 are already mothers or
pregnant with their first child. The proportion of
teenage women who have started childbearing
increases from 2 percent among women age 15
to 41 percent among women age 19.

xxii * Summary of Findings
The interval between births is long in Nepal.
Half of all births in Nepal occur within just under
three years (32 months) of a previous birth. The
median birth interval did not change over the last
five years. The long period of breastfeeding in
Nepal (32 months) and the corresponding rela-
tively long period of postpartum amenorrhea (11
months) are factors contributing to the long birth
interval.

The mean ideal number of children among ever-
married women declined only slightly from 2.9
in 1996 to 2.6 in 2001. Nevertheless, women in
Nepal continue to revise downward the number
of children they would like to have. Sixty-six
percent of currently married women either want
no more children or have been sterilized accord-
ing to the 2001 NDHS, compared with
59 percent found in the 1996 NFHS. If all un-
wanted births were prevented, the total fertility
rate would fall to 2.5 births per woman.

As in the 1996 NFHS, the 2001 NDHS gathered
complete pregnancy histories from women and
hence provides information on pregnancy out-
comes. Eight percent of all pregnancies that oc-
curred in the ten years preceding the survey did
not end in a live birth, with pregnancy losses
highest among women age 40-44 (13 percent)
and slightly higher among urban women
(9 percent) than among rural women (8 percent).

FAMILY PLANNING

Findings from the 2001 NDHS show that
knowledge of family planning is nearly univer-
sal among Nepalese women and men. Knowl-
edge of modern methods is generally much
higher than knowledge of traditional methods,
with women and men being most familiar with
female and male sterilization. The mass media
are important sources of information on family
planning. Three in five women and seven in ten
men have heard or seen messages about family
planning on the radio, on television, or in print
media. The majority of couples approve of
family planning. Discussion of family planning
between spouses continues to be relatively un-
common, with only two in five women and one
in two men who know of a contraceptive

method having discussed family planning with
their spouse in the year before the survey.

The contraceptive prevalence rate among cur-
rently married Nepalese women is 39 percent.
There has been an impressive increase in the use
of contraception in Nepal over the last 25 years,
with the increase in current use highest in the
most recent five-year perioda 35 percent in-
crease between 1996 and 2001. During this pe-
riod, the use of modern methods increased from
26 percent to 35 percent among currently mar-
ried women, with the increase largely attributed
to the increase in the use of injectables and fe-
male sterilization. There has been a twofold in-
crease in the share of temporary methods over all
modern methods in the last decade and a decline
in the share of permanent methods overall. Nev-
ertheless, there continues to be a marked discrep-
ancy between ever use of contraception and cur-
rent use. One in two currently married women
has ever used a modern method of family plan-
ning, compared with only one in three who is
currently using. Similarly, three-fifths of cur-
rently married men have ever used a modern,
method compared with slightly more than two-
fifths who are current users.

The most widely used modern method is female
sterilization (15 percent among currently married
women), followed by injectables (8 percent) and
male sterilization (6 percent). Currently married
men report a higher use of contraceptives with
the largest male/female discrepancy in the use of
condoms, with twice as many currently married
men as currently married women reporting using
condoms (6 percent versus 3 percent). Men also
report a much higher use of female sterilization
(17 percent) and injectables (10 percent).

The government sector supplies four in five fe-
male current users, with more than one in four
users obtaining their method from government
hospitals and clinics and another one in four
from mobile camps (serving sterilization users
alone). Fourteen percent of female users obtain
their method from sub-health posts. The most
important nongovernment supplier of contracep-
tives is the Family Planning Association of Ne-
pal (FPAN), which serves 5 percent of users,
while the private medical sector supplies contra-
ceptives to 7 percent of users, most of whom (6
Summary of Findings * xxiii
percent) obtain their supplies from pharmacies.
Among the three main sectors serving users, the
private medical sector is the most sensitive to
client needs. Two-thirds of women who ob-
tained their method for the first time from the
private medical sector were informed about side
effects or problems of the method used, 56 per-
cent were informed about what to do if they ex-
perienced side effects, and one in two were in-
formed of other methods that could be used. The
government sector is the least responsive to cli-
ent needs, with only about one in three women
being adequately informed.

The two most important reasons for not intend-
ing to use contraception in the future among cur-
rently married women are subfecun-
dity/infecundity and fear of side effects, with
more than one in four women and one in five
women, respectively, citing these reasons. One
in ten women also cites religious opposition as
an important reason for nonuse in the future.
More than one in two currently married men do
not intend to use a method in the future because
of their wifes menopause or hysterectomy, one
in ten cites religious opposition, and 6 percent
cite fear of side effects.

In spite of the marked increase in the use of con-
traceptives in Nepal, there continues to be con-
siderable scope for increased use of family plan-
ning. Twenty-eight percent of currently married
women in Nepal have an unmet need for family
planning services, of whom 11 percent have a
need for spacing and 16 percent have a need for
limiting. At the same time, among women cur-
rently using a method, 36 percent are using for
limiting and 4 percent are using for spacing.
Taken together, two in three Nepalese women
have a demand for family planning. However,
only three-fifths of these womens demand is
currently being met. If all women with unmet
need were to use family planning, the contracep-
tive prevalence rate would increase from 39 per-
cent to 67 percent.

CHILD HEALTH

One in every 11 children born in Nepal dies be-
fore reaching age five. Slightly more than two in
three under-five deaths occur in the first year of
lifeinfant mortality is 64 deaths per 1,000 live
births, and child mortality is 29 deaths per 1,000
live births. During infancy, the risk of neonatal
deaths (39 per 1,000) is one and a half times as
high as the risk of postneonatal death (26 per
1,000). According to data collected in the 2001
NDHS, mortality levels have declined rapidly
since the early 1980s. Under-five mortality in
the five years before the survey is 58 percent of
what it was 10-14 years before the survey.
Comparable data for child mortality (50 percent)
and infant mortality (60 percent) indicate that the
pace of decline is somewhat faster for child mor-
tality than for infant mortality. The correspond-
ing figures for neonatal and postneonatal mortal-
ity are 61 percent and 58 percent, respectively.
This decline in childhood mortality levels is con-
firmed by data from other sources.

Sixty percent of children are fully vaccinated by
12 months of age, 83 percent have received the
BCG vaccination, and 64 percent have been
vaccinated against measles. Coverage for the
first dose of DPT is 83 percent, but this drops to
77 percent for the second dose and further to
71 percent for the third dose. Polio coverage is
much higher at 97 percent for the first dose,
96 percent for the second dose, and 90 percent
for the third dose. The percentage of children
age 12-23 months fully immunized by age one
has increased in the last five years by 67 per-
cent. The corresponding increases in the third
dose of DPT and polio are 39 percent and 87
percent, respectively, while BCG coverage in-
creased by 13 percent and measles vaccination
increased by 41 percent. The much higher in-
crease in polio coverage was primarily due to
the success of the intensive national immuniza-
tion day campaigns and other polio eradication
activities.

The prevalence of symptoms of acute respira-
tory infection (ARI) among children under five
years of age in the two weeks before the survey
was 23 percent, while 32 percent of children
below age five had a fever in the preceding two
weeks. Use of a health facility for the treatment
of symptoms of ARI and/or fever is low, with
less than one in four children taken to a health
facility.


xxiv * Summary of Findings
One in five children suffered from diarrhea at
some time in the two weeks before the survey.
Among these children, only one in five was
taken to a health facility for treatment. Nearly
one in two children received oral rehydration
therapy, with 32 percent treated with oral rehy-
dration salts and 27 percent receiving increased
fluids. Nevertheless, more than one-third of
children with diarrhea were not given any
treatment at all.

MATERNAL HEALTH

One in two pregnant women receives antenatal
care in Nepal, with 28 percent receiving care
from a doctor or nurse, midwife, or auxiliary
nurse midwife. In addition, 11 percent of
women receive antenatal care from a health as-
sistant or auxiliary health worker, 3 percent re-
ceive care from a maternal and child health
worker, and 6 percent receive care from a vil-
lage health worker. Most Nepalese women who
receive antenatal care get it at a relatively late
stage in their pregnancy and do not make the
minimum recommended number of antenatal
visits. Only one in seven women (14 percent)
makes four or more visits during their entire
pregnancy, while 16 percent of women report
that their first visit occurred at less than four
months of pregnancy. About half of mothers
who receive antenatal care report that they were
informed about the signs of pregnancy compli-
cations, while three in five women report that
their blood pressure was measured as part of
their routine antenatal care checkup. Forty-five
percent of women receive two or more doses of
tetanus toxoid injections during their most re-
cent pregnancy.

Institutional deliveries are not common in Ne-
pal. Less than one in ten births in the five years
preceding the survey took place in a health fa-
cility. Thirteen percent of births were attended
at delivery by a medical professional, with only
8 percent of births attended by a doctor and
3 percent attended by a nurse, midwife, or
auxiliary nurse midwife. Nearly one in four
births was attended by a traditional birth
attendant. Safe delivery kits were used in 9
percent of births delivered at home.

Postnatal care, an important component of ma-
ternity care, is crucial for monitoring and treat-
ing complications within the first two days after
delivery. Only 17 percent of mothers receive
postnatal care within the first two days after de-
livery. Even more troubling is that nearly four
in five mothers did not receive postnatal care at
all.

BREASTFEEDING AND NUTRITION

Breastfeeding is nearly universal in Nepal, and
the median duration of breastfeeding is long (34
months). Nearly one in three children is breast-
fed within one hour of birth, while two out of
three babies are breastfed within one day of
birth. This is an improvement over the last five
years. However, contrary to the World Health
Organizations recommendation, only two-
thirds of children less than six months of age
are exclusively breastfed. The use of a bottle
with a nipple is relatively rare in Nepal, with
only 4 percent of children under six months of
age and 2 percent of children 6-9 months of age
given something to drink from a bottle.

Micronutrient deficiency is an important cause
of childhood morbidity and mortality. Informa-
tion gathered in the 2001 NDHS shows that four
in five children age 6-59 months received vita-
min A supplementation in the most recent dis-
tribution. However, slightly more than one in
three children under three years of age con-
sumed fruits and vegetables rich in vitamin A at
least once in the seven days preceding the sur-
vey.

Undernutrition is significant in Nepal, with one
in two Nepalese children under five years of age
stunted (short for their age), 10 percent wasted
(thin for their age), and 48 percent underweight.
A comparison of the 2001 NDHS data with
other data on the nutritional status of children
collected in previous years shows that there has
been little improvement in the nutritional status
of children over the last decade.

The 2001 NDHS also collected information on
mothers nutritional status. Survey results show
that the level of chronic energy deficiency in
Nepal is relatively high. One in four women
Summary of Findings * xxv
(27 percent) falls below the 18.5 cutoff for the
body mass index (BMI), which utilizes both
height and weight to measure thinness. One in
seven women is shorter than 145 centimeters
and can be considered to be at nutritional risk.
Overall, 10 percent of recent mothers received
vitamin A postpartum, while 8 percent of
women reported night blindness during their
last pregnancy. Three in four women who gave
birth in the five years preceding the survey re-
ported not having taken iron/folic acid tablets
during their pregnancy, and another 14 percent
reported taking these tablets for less than 60
days during their pregnancy.

HIV/AIDS

Only one in two women (50 percent), compared
with nearly three in four men (72 percent), has
heard of AIDS. At the same time, 38 percent of
women and 67 percent of men believe there is a
way to avoid HIV/AIDS. The depth of womens
knowledge of HIV/AIDS is also much lower
than that of men. One in three women and one
in two men know of two or more programmati-
cally important ways to avoid HIV/AIDS.
About one in three women mentioned use of
condoms and limiting the number of sexual
partners as specific ways to avoid HIV/AIDS,
compared with 63 percent and 54 percent of
men, respectively. In addition, about two-fifths
of women and three-fifths of men say a healthy-
looking person can have AIDS and that
HIV/AIDS can be transmitted from a mother to
her child. Fourteen percent of women and 23
percent of men have discussed HIV/AIDS with
their spouse.

An important component of AIDS prevention
programs is the promotion of safe sex. The
NDHS sought to determine the proportion of
men who had sexual relationship with women
other than their wife. The data show that the
overwhelming majority of married Nepalese
men (98 percent) did not have sex with anyone
else other than their wife in the 12 months pre-
ceding the survey. Knowledge of condoms is
important information from the programs per-
spective. Although 70 percent of currently mar-
ried women know where to obtain condoms,
only half of them could get condoms by them-
selves. Eighty-four percent of currently married
men know of a source of condoms. Condom
use is much less common with a spouse than
with a noncohabiting partner. Only 6 percent of
men have used a condom with a spouse, com-
pared with 45 percent of men who have used a
condom with a noncohabiting partner.

WOMENS STATUS

The 2001 NDHS also sheds some light on the
status of women in Nepal. Only 4 percent of
currently married women are in a polygynous
union, with older women more likely to have
cowives than younger women. However, poly-
gyny appears to have been on the decline over
the last five years, falling from 6 percent in
1996.

Women in Nepal are generally less educated
than men, with a median of less than 1 year of
schooling, compared with 1.4 years among
males. This gap in gender has not narrowed in
recent years. The net attendance ratio, which
indicates participation in primary schooling
among those age 6-10 years and secondary
schooling among those age 11-15 years, shows
a 13 percentage point difference at the primary-
school level and an 8 percentage point differ-
ence at the secondary-school level.

Female employment is high in Nepal, with more
than four-fifths of women employed at the time
of the survey. The more educated a woman, the
less likely she is to be currently employed. Most
working women (91 percent), however, are in
the agricultural sector. Only 15 percent of
working women earn cash for their work, while
the majority of working women (71 percent) are
not paid. One-third of working women are self-
employed. Four-fifths of women (79 percent)
enjoy a degree of autonomy in spending their
cash earnings, while more than one-fifth of
working women have no say in how their earn-
ings should be used. Fifty-four percent of
women contribute to half or more of the house-
hold expenditures.

With the exception of what food to cook, hus-
bands in Nepal have a greater say in decision-
making than wives. One in two currently mar-
xxvi * Summary of Findings
ried women stated that their husband alone has
a final say in their health care, two in five
women stated that their husband makes the sole
decision on the purchase of large household
items, while one in three stated that they needed
their husbands permission to visit family or
relatives and to make daily household pur-
chases. Twenty-nine percent of ever-married
women believe that a husband is justified in
beating his wife for at least one reason. One in
four agrees that wife beating is justified if a
woman neglects her children, and 12 percent
agree that a husband is justified in beating his
wife if she goes out without telling him. Never-
theless, less than 10 percent of women feel that
a husband is justified in beating his wife if she
refuses to have sex with him, burns the food, or
argues with him. An overwhelming majority of
Nepalese women (90 percent) agree that a
woman can refuse sex with her husband if she
knows that he has a sexually transmitted dis-
ease, if he has sex with other women, if she has
recently given birth, or if she is not in the mood.







NEPAL
CHINA
INDIA
Mountains
Hills
Terai
EASTERN
REGION
CENTRAL
REGION
WESTERN
REGION
MID-WESTERN
REGION
FAR-WESTERN
REGION
GORKHA
SOLUKHUMBU
SANKHUWASABHA
TAPLEJUNG
R
A
M
E
C
H
H
A
P
RASUWA
NUWAKOT
DHANKUTA
ILAM
P
A
N
C
H
T
H
A
R
T
E
R
H
A
T
H
U
M
BHOJPUR
KHOTANG
OKHALDHUNGA
DOLAKHA
UDAYAPUR
SINDHULI
MAKAWANPUR
KABHREPALANCHOK
LALITPUR
BHAKTAPUR
KATHMANDU
Ecological Regions
SINDHUPALCHOK
Introduction * 1
INTRODUCTION 1

1.1 GEOGRAPHY AND ECONOMY
GEOGRAPHY

Nepal is a landlocked country nestled in the foothills of the Himalayas. It occupies an area
from 2622' to 3027' north latitude and 804' to 8812' east longitude (Central Bureau of Statistics,
2001b). It shares its northern border with the Tibetan Autonomous Region of the Peoples Republic
of China and its eastern, southern, and western borders with India.

Nepal is rectangular in shape and averages 885 kilometers in length (east to west) and
193 kilometers in width (north to south). The total land area of the country is 147,181 square
kilometers and its population, according to the 2001 Census preliminary report, is approximately
23.2 million. Nepal is predominantly rural with only about 14 percent of the population living in
urban areas (Central Bureau of Statistics, 2001a).

Topographically, Nepal is divided into three distinct ecological zones. These are the
mountains, hills, and terai (or plains). The mountain zone ranges in altitude from 4,877 meters to
8,848 meters above sea level and covers a land area of 51,817 square kilometers. Because of the
harsh terrain, transportation and communication facilities in this zone are limited and only about 7
percent of the total population lives there. In contrast, the hill ecological zone, which ranges in
altitude from 610 meters to 4,876 meters above sea level, is densely populated. About 44 percent of
the total population of Nepal lives in the hill zone, which covers an area of 61,345 square kilometers.
This zone also includes a number of fertile valleys such as the Kathmandu and Pokhara valleys.
Although the terrain is also rugged in this zone, because of the higher concentration of people,
transportation and communication facilities are much more developed there than in the mountains.
Unlike the mountain and hill zones, the terai zone in the southern part of the country can be regarded
as an extension of the relatively flat Gangetic plains. This area, which covers 34,019 square
kilometers, is the most fertile part of the country. Although it constitutes only about 23 percent of the
total land area in Nepal, 49 percent of the population lives there. Because of its relatively flat terrain,
transportation and communication facilities are more developed in this zone than in the other two
zones of the country, and this has attracted newly emerging industries.

In Nepal, climatic conditions vary substantially by altitude. In the terai, temperatures can go up
to 44 Celsius in the summer and fall to 5 Celsius in the winter. The corresponding temperatures
for the hill and mountain areas are 41 Celsius and 30 Celsius, respectively, in the summer, and 3
Celsius and far below 0 Celsius, respectively, in the winter. The annual mean rainfall in the
kingdom is about 1,500 millimeters (Central Bureau of Statistics, 1996).

For administrative purposes, Nepal has been divided into five development regions, 14 zones,
and 75 districts. Districts are further divided into village development committees (VDCs) and
sometimes into urban municipalities. A VDC consists of nine wards, while the number of wards in
an urban municipality depends on the size of the population as well as on political decisions made by
the municipality itself. At present, there are 3,914 VDCs and 58 municipalities in Nepal.
2 * Introduction

Nepal is a multiethnic and multilingual society. The 1991 Census identified 60 caste or ethnic
groups and subgroups of the population. Some of the major groups consist of the following
percentages of the population: Chetri and Thakuri (18 percent), Brahmins (14 percent), Magar (7
percent), Tharu and Rajbanshi (7 percent), Newar (6 percent), Tamang (6 percent), Kamia major
occupational group that originated in the hills (5 percent), Yadav and Ahirs (4 percent), Muslims (4
percent), Rai and Kiranti (3 percent), and Gurung (2 percent) (Central Bureau of Statistics, 1995).
1


The 1991 Census of Nepal lists 20 different languages or dialects prevalent in the country
(Central Bureau of Statistics, 1995). These languages originated from two major groups: the Indo-
Aryans, who constitute about 80 percent of the population, and the Tibetan-Burmese, who constitute
about 17 percent of the population. Nepali is the official language of the country and is the mother
tongue of more than 50 percent of the population. However, it is used and understood by most of the
population and is the national language of Nepal. The other two major languages are Maithili and
Bhojpuri, spoken by about 8 percent and 5 percent of the population, respectively.

Nepal is a Hindu kingdom with more than 86 percent of its population following the Hindu
religion. The second largest religious group is Buddhists (8 percent), and Muslims constitute about 4
percent of the total population (Central Bureau of Statistics, 1995).
ECONOMY

The estimated per capita gross domestic product (GDP) for the year 1999/2000 is US $244
(Central Bureau of Statistics, 2001b). About 80 percent of the Nepalese population continues to rely
on agriculture for their livelihood. The recent Human Development Indicators (HDI) report from the
United Nations Development Program (UNDP) shows marginal growth in agricultural productivity
in the country. This is predominantly due to fragmentation of land, poor access to technology, and
poor rural accessibility (UNDP, 2001). On the other hand, growth in the nonagricultural sector,
which is largely driven by growth in the urban service sector, is notable. Therefore, Nepals overall
economic growth is mainly due to growth in the nonagricultural sector, which now contributes about
60 percent of the GDP, compared with 40 percent 15-20 years ago (UNDP, 2001). Because of
variations in the climatic and rainfall conditions, agricultural production varies by ecological zones.
In the terai, rice is the main crop, followed by wheat and corn. In the hills, the major crops are corn
and rice, followed by wheat, and in the mountains, corn, rice, and wheat are grown (Central Bureau
of Statistics, 1995). Forty-eight percent of the GDP comes from the service sector, and the
agricultural sector accounts for 42 percent of the GDP. The manufacturing sector accounts for 10
percent of the economy (Ministry of Finance, 1996).
1.2 POPULATION

Table 1.1 provides a summary of the basic demographic indicators for Nepal from census
data for 1971, 1981, 1991, and 2001. The population has doubled in 30 years. The population
growth rate increased from 2.1 in 1971 to 2.6 in 1981, then declined to 2.1 in 1991 (Central Bureau
of Statistics, 1995) and increased to 2.3 in 2001 (Central Bureau of Statistics, 2001a). The population



1
More recent information from the 2001 Population Census is not available at the time of publication of this
report. The distribution of the population by ethnicity and religion is not expected to differ much from the findings in the
1991 Population Census.
Introduction * 3
density has doubled over three decades from 79 persons per square kilometer in 1971 to 158 persons
per square kilometer in 2001. Nepal is predominantly rural; nevertheless, the urban proportion has
increased steadily over the last 30 years, from 4 percent in 1971 to 14 percent in 2001. The life
expectancy in Nepal is improving, increasing by about 13 years for males and females between 1971 and
1991. Male life expectancy is slightly higher than female life expectancy.

Table 1.1 Basic demographic indicators
Selected demographic indicators for Nepal, 1971-2001

Indicator
1971
Census
a

1981
Census
a

1991
Census
a

2001
Census
b



Population (millions)

Intercensal growth
rate (percent)

Density (pop./km
2
)

Percent urban

Life expectancy
Male
Female

11.6

2.1

79

4.0


42.0
40.0

15.0


2.6

102

6.4


50.9
48.1

18.5


2.1

126

9.2


55.0
53.5

23.2


2.3

158

14.2


u
u

u = Unknown (not available)

a
Central Bureau of Statistics, 1995
b
Central Bureau of Statistics, 2001a




1.3 POPULATION AND REPRODUCTIVE HEALTH POLICIES AND PROGRAMS
EVOLUTION OF POPULATION POLICY

Family planning emerged as one of the major components of Nepals planned development
activities in 1968 with the implementation of the Third Five-Year Development Plan (1965-1970).
This is when the Nepal Family Planning and Maternal and Child Health Project (FP/MCH) under the
Ministry of Health was launched in the government sector. Until then, family planning activities
were undertaken by the Family Planning Association of Nepal (FPAN), which was established in
1959 to create awareness among the people about the need and importance of family planning. Very
little was done to directly regulate population growth until 1965 when a family planning project was
established under the maternal and child health section of the Ministry of Health. Limited family
planning services were offered through the existing maternal and child health clinics.

The Fourth Development Plan (1970-1975) targeted the provision of family planning services
to 15 percent of married couples by the end of the plan period. From the Fifth Five-Year
Development Plan (1975-1980) onward, family planning services were greatly expanded through
outreach workers and serious attempts were made to reduce the birth rate by direct and indirect
means. To coordinate the governments multisectoral activities in population and reproductive
health, a population policy coordinating board was established in 1975 under the National Planning
Commission. In 1978, this board was upgraded to become the National Commission on Population
(NCP). It was further reorganized under the chairmanship of the prime minister and maintained its
own secretariat to plan, monitor, and coordinate population activities both at the government and
private-sector levels.
4 * Introduction

Subsequent development plans dealt with the population issue from both a policy and
programmatic point of view. From the Fifth Plan until the end of the Seventh Plan (1985-1990),
population policies and programs not only emphasized family planning issues in the short term but
also focused on long-term concerns to encourage the small family norm through education and
employment programs aimed at raising womens status and decreasing infant mortality. This
included launching population-related programs in reproductive health, agriculture, forestry,
urbanization, manpower and employment, education, and womens development, as well as community
development programs. In 1990, the NCP was dissolved and its role was given to the Population Division of
the National Planning Commission.

In 1995, the Ministry of Population and Environment (MOPE) was established as a separate
ministry for population-related activities and is viewed as the reflection of a strong government
commitment to population programs. The ministry is primarily responsible for formulating and
implementing population policies, plans, and programs and for monitoring and evaluating those
programs. This ministry, along with the Ministry of Health, is also responsible for implementing
programs of action recommended by the International Conference on Population and Development
(ICPD). The implementation of health-related population programs in reproductive health such as
family planning, safe motherhood, adolescent reproductive health, sexually transmitted diseases
(STDs), and infertility nevertheless falls under the purview of the Ministry of Health. In 1996, the
government established a National Population Committee composed of ministers from various
ministries and chaired by the prime minister to provide strong political leadership and guidance in
formulating population policies and coordinating, implementing, monitoring, and evaluating
population activities.

The Eighth Development Plan (1992-1997) continued with the integrated development
approach taken in earlier development plans. The Eighth Plan emphasized the family planning and
maternal and child health program, the main objectives of which were to control the growth of the
population in a planned way and to improve the standard of living of people by minimizing the
possible adverse effects of population growth on the economic and social development of the country
(Ministry of Population and Environment, 1998).

The Ninth Development Plan (1997-2002) was developed with a vision for a 20-year, long-
term plan. Poverty alleviation is the main thrust of the Ninth Plan. Major strategies adopted by the
plan include reduction in population growth through social awareness, expansion of education, and
family planning programs. The long-term objective of the plan is to lower fertility to replacement
level in the next 20 years. The immediate objectives of the Ninth Plan are to attract couples to adopt
a two-child family norm, to implement various programs to lower the fertility rate to replacement
level, and to make high-quality family planning and maternal and child health services easily
available and accessible. In agreement with the goals stated in Cairo by the ICPD and in Beijing by
the Womens Conference, the Ninth Plan has adopted a policy of improving the quality of services.
The current plan is geared toward creating demand for FP/MCH services, safer motherhood,
postnatal and antenatal care, client satisfaction, and increased male responsibility for reproductive
health. It is also focused on the involvement of nongovernmental organizations and community-
based organizations in the promotion of high-quality and effective services (Ministry of Population
and Environment, 1998).


Introduction * 5
FAMILY PLANNING PROGRAMS

Family planning services in Nepal were started by the FPAN in 1959. Initially, its services
were limited to the Kathmandu valley. The pioneering work of the FPAN led to the establishment of
the semiautonomous Nepal Family Planning and Maternal and Child Health Project (NFP & MCH
Project) in November 1968 at the government level. This project was gradually expanded to cover
all 75 districts in Nepal.

Family planning services have become an integral part of government health services.
Currently, temporary family planning methods (condoms, the pill, and injectables) are provided on a
regular basis through national, regional, zonal, and district hospitals, primary health care centers or
health centers, health posts, sub-health posts and peripheral health workers, and volunteers. Services
such as Norplant implants and IUD insertions are only available at a limited number of hospitals,
health centers, and selected health posts where trained manpower is available. Depending on the
district, sterilization services are provided at static sites (21 districts) through scheduled seasonal
or mobile outreach services.

At the central level, the Family Health Division in the Department of Health Services is
responsible for planning, supervising, and implementing family planning activities. The National
Health Training and Regional Training Centers are responsible for training fieldworkers for
reproductive health services. Information, education, and communication (IEC) activities on
reproductive health are carried out by the National Health Education, Information, and
Communication Center in the Department of Health Services and by the IEC section of MOPE.

Besides government programs, a number of nongovernmental organizations (NGOs) are also
involved in the delivery of family planning services at the grass-roots level. These include FPAN, the
Contraceptive Retail Sales (CRS) Company, the Nepal Red Cross Society, Save the Children Fund
(UK and USA), the Adventist Development Relief Agency (ADRA), Marie Stopes International
(MSI), the United Mission to Nepal (UMN), the Nepal Fertility Care Center (NFCC), the Center for
Development and Population Activities (CEDPA), the Asia Foundation (TAF), and CARE.

Among these NGOs, FPAN, NFCC, MSI, UMN, and ADRA deliver the most sterilization
services, while CEDPA, TAF, CRS, Save the Children, and CARE deliver a significant number of
services for temporary methods and referrals for sterilization. These NGOs are located throughout
the country, serving the most densely populated districts as well as some of the most remote areas of
Nepal.

In addition to service delivery, NGOs like World Education, Inc., are involved in behavior
change communication programs including IEC and adult literacy classes with a focus on family
planning. Although the number of users of family planning who receive services from NGOs are
modest compared with those served by the public sector, they complement the Ministry of Healths
ongoing efforts to expand the availability of family planning methods.
1.4 OBJECTIVES AND ORGANIZATION OF 2001 NDHS SURVEY

The main objective of the 2001 Nepal Demographic and Health Survey (NDHS) is to generate
reliable information on fertility; child mortality; knowledge of, use of, and demand for contraception;
utilization of maternal and child health services; nutrition; and knowledge of HIV/AIDS. This
information is useful for policy formulation, planning, monitoring, and evaluation of programs both
6 * Introduction
at the national and regional levels. The 2001 NDHS is the sixth in a series of national-level
population and health surveys. It is the second nationally representative, comprehensive survey
conducted as part of the global Demographic and Health Survey (DHS) program, the first being the
1996 Nepal Family Health Survey (NFHS). The 2001 NDHS data are comparable to data collected in
DHS surveys in other developing countries. The survey collected demographic and health
information from a nationally representative sample of ever-married women and men in the
reproductive age groups of 15-49 and 15-59, respectively, and provides updated information at the
national, regional, and subregional levels, as well as for urban and rural areas separately. The 2001
NDHS is the first in the history of demographic and health surveys conducted in Nepal that included
a male sample.

The 2001 NDHS was carried out under the aegis of the Family Health Division of the
Department of Health Services, Ministry of Health, and was implemented by New ERA, a local
research organization, which also conducted the 1996 NFHS. ORC Macro provided technical support
through its MEASURE DHS+ Project. The survey was funded by the U.S. Agency for International
Development (USAID) through its mission in Nepal.

A total of 257 enumeration areas (EAs)215 in the rural areas and 42 in the urban areaswere
selected using probability proportional to size. Of the total rural clusters sampled, six could not be
covered due to security concerns, reducing the total number of EAs to 251. A complete household
listing operation of the sampled clusters was conducted before the main survey from which
individual households were selected.

Three types of questionnaires were used to gather demographic and health data: the Household
Questionnaire, the Womens Questionnaire, and the Mens Questionnaire. The content and design of
the questionnaires were based on the MEASURE DHS+ Model B Questionnaire. The English
questionnaires were circulated among the various organizations for feedback and later translated into
the three main local languagesNepali (the national language), Maithali, and Bhojpuri. They were
finalized after pretesting. A four-week training course was organized for field supervisors,
interviewers, field data editors, quality control teams, and data processing staff on various aspects of
the survey such as questionnaire content, interviewing techniques, field procedures, and monitoring
of data quality. Data were collected by 11 teams, each team comprising a field supervisor, three
female interviewers, a male interviewer, and a data editor. Data quality was monitored through
constant field supervision and from the results of field check tables that were produced periodically
from data entered onto computers.

The fieldwork was conducted from the fourth week of January to the end of June 2001. Of the
total 8,864 households selected, 8,634 were found to be valid, occupied households and 8,602
households were successfully interviewed, giving a response rate of nearly 100 percent (Table 1.2).
From these households, 8,885 eligible women (ever-married women age 15-49) were identified and
8,726 were successfully interviewed yielding a response rate of 98 percent. Every third household
was selected for the male survey, and from these households, 2,353 eligible men (ever-married men
age 15-59) were identified. Of these, 2,261 men were successfully interviewed, yielding a response
rate of 96 percent. Survey operational procedures and sample design are discussed in greater detail in
Appendix A.


Introduction * 7





























Table 1.2 Results of the household and individual interviews

Number of households, number of interviews, and
response rates, according to residence, Nepal 2001


Residence

Result Urban Rural Total


Household interviews

Households selected 1,271 7,593 8,864

Households occupied 1,223 7,411 8,634

Households interviewed 1,218 7,384 8,602



Household response rate 99.6 99.6 99.6



Interviews with women

Number of eligible women 1,191 7,694 8,885

Number of eligible women
interviewed

1,154

7,572

8,726




Eligible woman response rate 96.9 98.4 98.2



Interviews with men

Number of eligible men 329 2,024 2,353

Number of eligible men
interviewed 304 1,957 2,261




Eligible man response rate 92.4 96.7 96.1


Household Population and Housing Characteristics * 9
2
HOUSEHOLD POPULATION AND
HOUSING CHARACTERISTICS


This chapter provides a summary of the demographic and socioeconomic characteristics of
the household population in the 2001 Nepal Demographic Health Survey (NDHS). It provides
valuable input for social and economic development planning and is also useful in understanding and
identifying the major factors that determine or influence the basic demographic indicators of the
population. In this chapter, the 2001 NDHS data have, in some instances, been compared with data
from the 1991 and 2001 Censuses and the 1996 Nepal Family Health Survey (NFHS).

The 2001 NDHS collected information about all usual residents of a selected household (the
de jure population) and persons who had slept in the selected household the night before the
interview (the de facto population). The difference between these two populations is very small, and
since past surveys have looked at the de facto population, for comparison purposes, all tables in this
report refer to the de facto population, unless otherwise specified. A household is defined as a
person or group of persons who live and eat together.
2.1 AGE AND SEX COMPOSITION OF THE HOUSEHOLD POPULATION

Age and sex are important demographic variables and are the primary basis of demographic
classification in vital statistics, censuses, and surveys. They are also important variables in the study
of mortality, fertility, and nuptiality. In general, a cross-classification with sex is useful for the
effective analysis of all forms of data obtained in surveys.

In most developing countries, age is of little significance to the majority of the population and
especially to those living in rural areas. Because it is well documented that in Nepal ages are poorly
reported, considerable emphasis was placed during interviewer training on obtaining accurate age
information. There are also several built-in checks in the questionnaire that allowed interviewers to
verify the accuracy of the information recorded on age. An examination of the quality of the data in
relation to age reporting indicates that there is some preference for ages ending in 0 and 5, and as
expected, this age heaping is more severe at older ages (Table C.1 and Figure 2.1). The typical
pattern of heaping on age 12 is also evident. Nevertheless, age reporting in the 2001 NDHS is better
than age data from most other sources and shows no serious biases in reporting. Information on the
age and sex of each household member was obtained from the household head or some other
responsible adult member of the household. Age reporting appears to be better among women and
men in the reproductive age groups of 15-49 and 15-59, respectively, presumably because most of
these women reported their own age in the individual questionnaires, as opposed to only one-third of
the men who live in households selected for the mens survey. Another measure of the quality of the
age data is the very small number of persons whose ages were recorded as not known or
missingtwo males and two females (Table C.1).


Household Population and Housing Characteristics * 11
The overall sex ratio, the number of males per 100 females, is 90, which is lower than that
obtained in the 2001 Census (100) and the 1996 NFHS (93).
2
The sex ratio differs by residence
(Table 2.1). Urban areas have a higher sex ratio (97) than rural areas (89). The sex ratio is markedly
lower among the working-age population, which was also the case in the 1996 NFHS. A low sex
ratio among the working-age population, particularly in rural areas, may be attributed to the high rate
of out-migration of males to the urban areas of Nepal, as well as to other countries, including India,
in search of short- and long-term employment.

The age structure of the household population observed in the survey is typical of a youthful
population (see population pyramid in Figure 2.2). Nepal has a pyramidal age structure due to the
high fertility levels prevailing in the past. Children under 15 years of age account for more than two-
fifths of the population, a feature of populations with high fertility levels (Table 2.1). Fifty-two
percent of the population is in the age group 15-64 and 4 percent are over 65. The distribution of the
population by age group is similar to that in the 1996 NFHS.


Table 2.1 Household population by age, sex, and residence
Percent distribution of the de facto household population by five-year age groups, according to sex and
residence, Nepal 2001

Urban Rural Total

Age Male Female Total
Sex
ratio Male Female Total
Sex
ratio Male Female Total
Sex
ratio

<5 10.7 9.9 10.2 104.9 16.6 15.3 15.9 96.4 15.9 14.7 15.3 97.0
5-9 13.3 11.6 12.4 111.6 16.6 14.4 15.4 102.1 16.2 14.1 15.1 102.8
10-14 13.2 13.4 13.3 95.5 14.6 12.2 13.3 106.8 14.5 12.3 13.3 105.6
15-19 10.5 11.6 11.1 87.7 9.1 10.3 9.8 78.9 9.3 10.4 9.9 79.8
20-24 10.2 11.7 10.9 84.3 6.2 8.4 7.3 65.4 6.6 8.7 7.7 67.9
25-29 9.0 8.4 8.7 103.8 5.7 7.5 6.7 67.7 6.1 7.6 6.9 71.5
30-34 7.3 7.0 7.2 101.9 5.3 6.5 5.9 73.2 5.5 6.5 6.1 76.1
35-39 5.6 5.8 5.7 93.0 4.9 5.2 5.1 83.8 5.0 5.3 5.1 84.8
40-44 4.4 4.9 4.7 86.8 4.0 4.4 4.2 80.8 4.1 4.5 4.3 81.4
45-49 4.3 3.9 4.1 107.2 3.7 3.6 3.7 91.8 3.8 3.6 3.7 93.4
50-54 2.7 3.0 2.8 88.7 3.2 3.7 3.5 74.8 3.1 3.7 3.4 75.9
55-59 2.7 2.7 2.7 95.0 2.8 2.5 2.6 98.7 2.8 2.5 2.7 98.3
60-64 2.5 2.0 2.3 121.7 2.5 2.2 2.4 102.5 2.5 2.2 2.3 104.2
65-69 1.5 1.9 1.7 77.4 2.1 1.7 1.9 112.0 2.0 1.7 1.8 108.2
70-74 0.9 0.9 0.9 107.6 1.3 1.0 1.1 109.7 1.2 1.0 1.1 109.5
75-79 0.6 0.5 0.5 106.5 0.8 0.6 0.7 109.2 0.8 0.6 0.7 109.0
80 + 0.5 0.8 0.6 69.0 0.5 0.4 0.5 102.7 0.5 0.5 0.5 97.5

Total 100.0 100.0 100.0 97.0 100.0 100.0 100.0 89.0 100.0 100.0 100.0 90.0
Number 2,172 2,240 4,412 4,412 18,661 21,013 39,674 39,674 20,833 23,253 44,086 44,086




2
The marked difference in the sex ratio between the 2001 Census and the 2001 NDHS could be because the sex ratio
from the census is based on the de jure population, whereas the sex ratio obtained from the 2001 NDHS is based on the
de facto household population.

12 * Household Population and Housing Characteristics
Figure 2.2 Population Pyramid, Nepal, 2001
80+
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
0 2 4 6 8 10 0 2 4 6 8 10
Nepal 2001
Age
Male
Percent
Female

2.2 HOUSEHOLD COMPOSITION

Table 2.2 presents the distribution of households by selected background characteristics. This
information is useful for several reasons. For example, female-headed households are often found to
be poorer than male-headed households and the size and composition of a household influences the
allocation of limited resources and affects the living conditions of individuals in the household.

Table 2.2 Household composition
Percent distribution of households by sex of head of
household and by household size, according to
residence, Nepal 2001

Residence
Characteristic Urban Rural Total
Sex of head of household
Male 83.3 83.9 83.9
Female 16.7 16.1 16.1

Total 100.0 100.0 100.0

Number of usual members
1 5.1 3.8 4.0
2 8.7 8.1 8.2
3 12.9 11.3 11.5
4 17.8 16.7 16.8
5 19.1 18.5 18.5
6 14.3 14.8 14.7
7 9.2 10.7 10.6
8 4.7 6.3 6.1
9+ 8.1 9.7 9.6

Total 100.0 100.0 100.0
Number of households 900 7,702 8,602
Mean size 5.0 5.3 5.3
Note: Table is based on de jure members, of
household, i.e., usual residents



Household Population and Housing Characteristics * 13
Households in Nepal are predominantly headed by males regardless of the type of residence
(84 percent).

The average household size is 5.3 persons, which is slightly lower than in the 1996 NFHS
(5.5). The average household size is slightly larger in rural areas (5.3) than in urban areas (5.0).
2.3 EDUCATION OF HOUSEHOLD MEMBERS
EDUCATIONAL ATTAINMENT OF THE HOUSEHOLD POPULATION

The level of education attained by the population is an important indicator of social
development. In addition, education has been found to influence reproductive behavior, the use of
contraceptives, the health of mothers and children, and hygienic habits. Tables 2.3.1 and 2.3.2 show
the distribution of the male and female household population age six years and above by the level of
education attended or completed according to age, residence, ecological zone, development region,
and subregion. In this report those who have never been to school are categorized as having no
education.

About one-third of males (32 percent) and three out of five females (60 percent) have no
education. Overall, 35 percent of males and 23 percent of females have some primary education
only, while 7 percent of males and 4 percent of females have completed primary education and gone
no further. Likewise, 18 percent of males and 9 percent of females have only some secondary
education, while three times as many males (9 percent) as females (3 percent) have completed
secondary education. The median number of years of schooling is 1.4 for males and less than 1 year
for females (the median for females is not shown because more than 50 percent of the female
household population in most of the categories have no education). An examination of the level of
education by age group reveals that there has been an improvement over time in the educational
attainment for both sexes. The proportion of males who have never been to school declines from 88
percent among the oldest age group (65 years or more) to 10 percent among those age 10-14 years.
The comparable proportion among females is 99 percent and 28 percent, respectively. Nevertheless,
the gender gap remains large. For example, 21 percent of males in the age group 6-9 have not been
to school, compared with 34 percent among females in the same age group.

Data also indicate that there is a wide gap between urban and rural areas in educational
attainment. Thirty-four percent of males and 63 percent of females in rural areas have never attended
school, compared with 14 percent of males and 36 percent of females in urban areas. For both sexes,
this difference is more pronounced at higher levels of education, presumably because of insufficient
numbers of higher educational facilities, inaccessibility, and less affordability in rural areas.

Among both women and men, the percentage with no education is lowest in the hill
ecological zone and almost the same in the terai and mountain zones. More than one-third of males
residing in the Central region (36 percent) reported having no education. Among females, the
highest percentage reporting no education is in the Far-western region (67 percent), followed closely
by the Central region (65 percent) and the Mid-western region (64 percent).




14 * Household Population and Housing Characteristics


Table 2.3.1 Educational attainment of household population: male
Percent distribution of the de facto male household population age six and over by highest level of education attended or completed, according to background
characteristics, Nepal 2001


Background
characteristic
No
education
Some
primary
Completed
primary
1

Some
secondary
Completed
secondary
2

More
than
secondary
Don't know/
missing Total
Number
of
men
Median
number of
years

Age
6-9 20.8 78.7 0.1 0.0 0.0 0.0 0.3 100.0 2,706 0.0
10-14 10.4 64.2 12.1 13.2 0.1 0.0 0.0 100.0 3,018 2.4
15-19 13.3 18.8 10.7 47.8 7.4 2.0 0.1 100.0 1,935 5.6
20-24 16.2 17.2 9.3 32.7 13.4 11.2 0.0 100.0 1,371 6.3
25-29 24.4 16.6 7.5 27.9 10.9 12.4 0.3 100.0 1,266 5.4
30-34 33.6 17.3 6.1 23.4 9.6 9.9 0.1 100.0 1,155 3.8
35-39 37.0 21.3 7.4 18.9 7.3 7.8 0.2 100.0 1,041 2.5
40-44 47.6 19.0 7.5 13.7 4.8 7.2 0.1 100.0 846 0.4
45-49 48.1 20.0 6.7 14.5 5.0 5.5 0.1 100.0 792 0.0
50-54 60.2 17.6 5.8 9.2 3.3 3.5 0.4 100.0 648 0.0
55-59 75.5 9.3 4.5 4.9 3.2 2.1 0.5 100.0 580 0.0
60-64 80.5 11.6 1.6 3.5 1.4 1.2 0.2 100.0 528 0.0
65+ 88.3 6.2 1.3 2.6 0.6 0.7 0.3 100.0 947 0.0

Residence
Urban 14.1 28.8 6.5 23.8 10.6 15.7 0.4 100.0 1,880 5.1
Rural 33.7 35.9 6.9 16.8 3.9 2.7 0.1 100.0 14,954 1.0

Ecological zone
Mountain 33.4 40.2 6.2 14.9 3.6 1.8 0.0 100.0 1,193 0.7
Hill 26.1 38.6 7.6 18.4 4.6 4.7 0.1 100.0 6,925 2.0
Terai 35.6 31.6 6.3 17.3 4.9 4.0 0.3 100.0 8,716 1.1

Development region
Eastern 29.0 35.7 6.6 19.1 5.4 4.0 0.2 100.0 4,348 1.8
Central 36.1 32.5 6.1 14.5 5.0 5.5 0.3 100.0 5,325 0.7
Western 27.8 35.5 7.8 20.5 4.5 3.8 0.1 100.0 3,357 2.1
Mid-western 32.9 36.4 6.3 17.9 3.4 3.0 0.1 100.0 2,261 1.1
Far-western 29.1 39.5 8.6 17.1 3.6 2.0 0.1 100.0 1,543 1.3

Subregion
Eastern Mountain 27.0 37.7 7.1 18.4 5.9 3.8 0.0 100.0 310 1.9
Central Mountain 35.0 43.6 5.6 12.4 2.9 0.5 0.0 100.0 400 0.1
Western Mountain 36.2 38.9 6.0 14.6 2.7 1.6 0.0 100.0 483 0.4
Eastern Hill 27.4 41.8 6.4 18.2 3.7 2.3 0.2 100.0 1,252 1.4
Central Hill 25.5 35.7 6.4 16.7 6.1 9.5 0.1 100.0 1,978 2.3
Western Hill 23.7 36.6 9.0 21.3 5.1 4.3 0.1 100.0 1,928 2.6
Mid-western Hill 28.3 43.0 7.8 16.6 2.8 1.5 0.1 100.0 1,151 1.3
Far-western Hill 28.9 39.4 9.2 18.1 2.9 1.3 0.2 100.0 616 1.1
Eastern Terai 30.0 32.7 6.6 19.5 6.1 4.8 0.2 100.0 2,786 2.0
Central Terai 43.3 28.9 6.0 13.2 4.6 3.5 0.5 100.0 2,947 0.0
Western Terai 33.5 34.1 6.2 19.4 3.6 3.2 0.1 100.0 1,429 1.4
Mid-western Terai 35.1 29.7 4.9 20.5 4.1 5.5 0.1 100.0 902 1.1
Far-western Terai 30.3 36.6 8.7 16.9 4.9 2.4 0.1 100.0 652 1.6

Total 31.6 35.1 6.8 17.6 4.7 4.1 0.2 100.0 16,834 1.4
Note: Total includes 2 men with missing information on age who are not shown separately.
1
Completed grade 5 at the primary level
2
Completed grade 10 at the secondary level




Household Population and Housing Characteristics * 15

Table 2.3.2 Educational attainment of household population: female
Percent distribution of the de facto female household population age six and over by highest level of education attended or completed, according
to background characteristics, Nepal 2001


Background
characteristic
No
education
Some
primary
Completed
primary
1

Some
secondary
Completed
secondary
2

More
than
secondary
Don't know/
missing Total
Number
of
women

Age
6-9 33.7 66.0 0.1 0.0 0.0 0.0 0.1 100.0 2,629
10-14 28.2 52.4 9.4 10.1 0.0 0.0 0.0 100.0 2,858
15-19 37.6 17.2 8.0 30.3 5.7 1.0 0.1 100.0 2,423
20-24 55.6 10.5 5.1 17.5 6.4 4.7 0.1 100.0 2,019
25-29 67.6 10.2 4.7 10.3 4.6 2.6 0.0 100.0 1,771
30-34 75.4 9.6 3.2 7.7 3.0 1.1 0.0 100.0 1,517
35-39 86.2 5.8 2.0 4.3 1.0 0.8 0.0 100.0 1,228
40-44 87.5 6.3 2.2 2.5 0.8 0.7 0.0 100.0 1,039
45-49 92.7 2.8 0.8 2.4 0.7 0.5 0.2 100.0 849
50-54 94.3 2.3 1.3 1.6 0.4 0.2 0.0 100.0 854
55-59 97.2 1.5 0.5 0.4 0.3 0.0 0.0 100.0 589
60-64 97.8 0.8 0.0 1.0 0.3 0.0 0.1 100.0 506
65+ 98.9 0.8 0.0 0.0 0.0 0.0 0.2 100.0 883

Residence
Urban 36.1 24.4 4.7 21.7 7.6 5.6 0.0 100.0 1,974
Rural 63.1 22.7 3.9 8.0 1.6 0.6 0.1 100.0 17,192

Ecological zone
Mountain 66.1 24.3 2.5 5.9 1.1 0.2 0.0 100.0 1,361
Hill 53.7 27.3 4.8 10.2 2.5 1.4 0.0 100.0 8,296
Terai 65.3 18.9 3.5 9.1 2.2 1.0 0.1 100.0 9,509

Development region
Eastern 55.5 24.0 4.9 12.1 2.4 1.1 0.0 100.0 4,840
Central 65.1 19.9 3.0 7.7 2.8 1.5 0.1 100.0 5,877
Western 53.8 25.8 5.3 11.7 2.3 1.1 0.1 100.0 4,019
Mid-western 64.4 22.6 3.4 7.3 1.5 0.7 0.0 100.0 2,573
Far-western 66.5 23.8 3.0 5.6 0.9 0.2 0.1 100.0 1,856

Subregion
Eastern Mountain 48.6 30.9 4.3 13.4 2.2 0.6 0.0 100.0 343
Central Mountain 65.5 27.4 1.9 4.4 0.7 0.1 0.0 100.0 458
Western Mountain 77.4 17.7 1.9 2.4 0.6 0.0 0.0 100.0 560
Eastern Hill 52.4 30.6 5.8 9.5 1.1 0.6 0.0 100.0 1,455
Central Hill 50.3 26.2 4.1 11.4 4.6 3.3 0.0 100.0 2,234
Western Hill 45.9 29.8 6.3 14.0 2.8 1.2 0.1 100.0 2,449
Mid-western Hill 63.9 24.9 3.7 6.1 1.4 0.0 0.0 100.0 1,385
Far-western Hill 72.6 20.7 2.6 3.7 0.3 0.0 0.2 100.0 774
Eastern Terai 57.7 20.0 4.5 13.2 3.1 1.4 0.0 100.0 3,043
Central Terai 75.5 14.3 2.3 5.5 1.8 0.4 0.1 100.0 3,185
Western Terai 66.2 19.6 3.7 8.1 1.4 0.9 0.1 100.0 1,571
Mid-western Terai 60.2 21.6 3.6 10.4 2.2 1.9 0.1 100.0 962
Far-western Terai 57.7 28.2 3.5 8.7 1.5 0.4 0.1 100.0 748

Total 60.4 22.9 4.0 9.4 2.2 1.1 0.1 100.0 19,166
Note: Total includes 2 women with missing information on age who are not shown separately.
1
Completed grade 5 at the primary level
2
Completed grade 10 at the secondary level


16 * Household Population and Housing Characteristics
The table shows the persistence of the gender gap in the level of education even among the
subregions. Although among males, the percentage that have never been to school is less than 45
percent in all subregions, among females, the percentage who have never been to school exceeds 50
percent in most of the subregions and exceeds 75 percent in two of the thirteen subregions (Western
mountain and Central terai).
SCHOOL ATTENDANCE RATIOS

The net attendance ratio (NAR) indicates participation in primary schooling for the
population age 6-10 and secondary schooling for the population age 11-15. The gross attendance
ratio (GAR) measures participation at each level of schooling among those of any age from 5 to 24.
The GAR is nearly always higher than the NAR for the same level because the GAR includes
participation by those who may be older or younger than the official age range for that level.
3
An
NAR of 100 percent would indicate that all those in the official age range of the level are attending at
that level. The GAR can exceed 100 percent if there is significant overage or underage participation
at a given level of schooling.

Table 2.4 presents the NAR and GAR for the de jure household population by level of
schooling of the male and female population age 5-24 years according to residence. The NAR is 73
percent at the primary level and 31 percent at the secondary level, while the GAR at the primary
level is more than two times as high as at the secondary level. Male attendance ratios are much
higher than female attendance ratios at both the primary and secondary levels. Attendance ratios are
also much higher in urban areas than in rural areas. Attendance ratios at the primary and secondary
levels are highest in the hill ecological region and the Western development region. At the primary
level, they are lowest in the terai ecological zone and Central region, while at the secondary level,
they are lowest in the mountain zone.




3
Students who are overage for a given level of schooling may have started school overage, may have repeated one or
more grades in school, or may have dropped out of school and later returned.


Household Population and Housing Characteristics * 17

Table 2.4 School attendance ratios


Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de jure household population by level of schooling and sex, according to
background characteristics, Nepal 2001


Net attendance ratio
1
Gross attendance ratio
2



Background
characteristic
Male Female Total Male Female Total
Gender
Parity
Index
3

PRIMARY SCHOOL


Residence


Urban 90.8 86.4 88.7 142.7 128.7 135.8 0.9


Rural 78.2 64.7 71.6 126.1 103.7 115.2 0.8





Ecological zone


Mountain 83.9 64.3 73.9 140.9 100.7 120.3 0.7


Hill 87.2 79.1 83.2 140.9 127.9 134.5 0.9


Terai 72.2 56.2 64.5 114.8 87.9 101.8 0.8





Development region


Eastern 82.6 66.3 74.9 133.3 113.0 123.6 0.8


Central 71.7 60.4 66.1 111.7 87.5 99.7 0.8


Western 83.8 77.6 80.7 135.6 123.9 129.8 0.9


Mid-western 78.7 62.6 71.1 129.3 103.9 117.3 0.8


Far-western 86.4 69.3 78.0 143.9 113.4 128.8 0.8





Subregion


Eastern Mountain 84.5 79.7 82.1 164.1 143.4 153.7 0.9


Central Mountain 88.7 69.7 79.4 130.2 105.3 118.0 0.8


Western Mountain 79.5 53.5 65.6 137.5 77.7 105.6 0.6


Eastern Hill 84.4 77.2 80.9 143.8 141.5 142.7 1.0


Central Hill 84.9 81.7 83.2 132.4 116.4 124.1 0.9


Western Hill 94.0 91.3 92.6 152.4 149.9 151.2 1.0


Mid-western Hill 83.3 64.4 74.8 132.4 106.8 120.9 0.8


Far-western Hill 87.1 64.7 76.3 143.2 107.6 126.1 0.8


Eastern Terai 81.5 58.9 70.9 124.9 94.1 110.5 0.8


Central Terai 62.0 45.2 53.9 97.7 66.1 82.5 0.7


Western Terai 70.4 58.7 64.6 113.5 88.1 101.0 0.8


Mid-western Terai 75.3 67.6 71.6 125.5 111.9 119.0 0.9


Far-western Terai 83.8 76.1 79.9 144.5 132.1 138.3 0.9





Total 79.3 66.5 73.0 127.5 105.9 116.9 0.8

SECONDARY SCHOOL




Residence


Urban 48.8 51.5 50.2 72.6 75.0 73.9 1.0


Rural 33.5 23.6 28.7 56.5 39.2 48.0 0.7





Ecological zone


Mountain 31.6 20.7 26.5 56.2 30.8 44.3 0.5


Hill 38.7 30.6 34.6 62.0 49.5 55.7 0.8


Terai 32.3 23.7 28.1 54.9 38.8 47.1 0.7





Development region


Eastern 34.4 29.4 31.9 59.5 51.5 55.5 0.9


Central 32.8 24.4 28.8 50.9 38.9 45.1 0.8


Western 41.4 33.7 37.6 65.4 50.9 58.3 0.8


Mid-western 30.6 22.7 26.6 57.2 34.1 45.5 0.6


Far-western 35.4 16.4 26.0 60.6 30.0 45.6 0.5





Subregion


Eastern Mountain 28.0 30.1 29.0 52.8 51.5 52.2 1.0


Central Mountain 31.9 21.3 26.9 52.9 31.5 42.7 0.6


Western Mountain 33.8 14.3 24.7 60.6 17.1 40.3 0.3


Eastern Hill 31.6 24.9 28.2 56.8 47.3 51.9 0.8


Central Hill 40.1 36.8 38.4 62.6 59.3 60.9 0.9


Western Hill 48.6 41.3 45.0 70.7 61.7 66.3 0.9


Mid-western Hill 31.4 21.6 26.5 52.7 33.8 43.2 0.6


Far-western Hill 31.9 10.0 20.9 61.0 22.3 41.6 0.4


Eastern Terai 36.7 31.7 34.2 61.8 53.7 57.8 0.9


Central Terai 28.5 15.1 22.5 43.3 23.9 34.6 0.6


Western Terai 30.3 22.2 26.3 57.1 34.6 46.0 0.6


Mid-western Terai 30.8 28.8 29.8 66.2 40.9 53.3 0.6


Far-western Terai 36.4 19.4 27.9 57.2 38.1 47.6 0.7





Total 35.0 26.5 30.8 58.0 43.0 50.6 0.7


1
The NAR for primary school is the percentage of the primary-school age (6-10 years) population that is attending primary school. The NAR for secondary school is
the percentage of the secondary-school age (11-15 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent.
2
The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population.
The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age
population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent.
3
The Gender Parity Index for primary school is the ratio of the primary school GAR for females to the GAR for males. The Gender Parity Index
for secondary school is the ratio of the secondary school GAR for females to the GAR for males.


18 * Household Population and Housing Characteristics

The repetition rate is the percentage of students in a given grade the previous school year who
are repeating that grade in the current school year. Likewise, the dropout rate is the percentage of
students in a given grade in the previous school year not attending school. By asking about the grade
that children were attending during the previous school year, it is possible to calculate dropout rates
and repetition rates. Table 2.5 indicates that the repetition rate is high in grade one (about one-third),
which may be related to the teachers decision to ensure a more uniform preparedness before
promoting children to grade two. The repetition rate declines significantly after grade one. Table 2.5
also shows that as the school grade rises, the dropout rate generally increases. Only 1 percent of
children drop out of school after attending grade one, compared with a dropout rate of 3 percent at
grades four and five.



Table 2.5 Grade repetition and dropout rates


Repetition and dropout rates for the de jure household population age 5-24 years by school grade,
according to background characteristics, Nepal 2001


Repetition rate
1
Dropout rate
2



School grade School grade


Background
characteristic 1 2 3 4 5 1 2 3 4 5

Sex



Male 31.6 10.1 7.1 6.0 6.4 1.2 1.5 2.1 3.2 3.0

Female 34.0 9.2 8.1 6.8 5.8 1.7 1.0 1.7 2.3 2.0



Residence

Urban 15.4 4.8 2.1 3.9 3.4 0.6 2.0 2.5 4.3 1.8

Rural 34.0 10.3 8.2 6.7 6.5 1.5 1.2 1.9 2.6 2.7


Ecological zone
Mountain 36.0 16.6 9.1 14.6 12.7 0.7 1.1 3.9 2.3 4.1
Hill 36.9 12.1 7.0 6.3 6.1 1.9 1.8 2.0 3.1 3.0
Terai 26.6 6.3 8.0 5.2 5.2 1.0 0.9 1.5 2.6 1.9

Development region
Eastern 30.1 13.1 11.9 6.1 8.2 1.7 0.5 1.4 2.7 2.8
Central 39.8 10.7 8.0 8.2 4.4 1.4 1.9 3.6 4.2 5.4
Western 28.3 6.2 5.7 4.4 5.2 0.5 1.2 0.5 0.6 1.4
Mid-western 36.1 6.8 3.9 3.0 8.7 2.4 1.9 2.5 4.0 0.0
Far-western 20.9 10.0 6.0 11.5 4.1 1.4 1.5 1.9 2.9 0.7

Subregion
Eastern Mountain 34.6 15.1 3.4 3.8 19.1 1.6 1.4 1.7 1.9 4.3
Central Mountain 44.2 20.0 10.5 23.8 12.9 0.8 0.0 3.5 2.4 9.7
Western Mountain 29.9 14.6 12.0 15.0 7.5 0.0 2.1 6.0 2.5 0.0
Eastern Hill 42.6 18.5 9.9 6.6 8.3 1.6 0.0 0.0 4.0 2.8
Central Hill 38.9 16.1 9.7 8.6 6.4 3.1 3.2 5.2 7.0 6.1
Western Hill 32.0 7.1 6.2 5.1 3.7 0.5 1.3 0.7 0.9 2.0
Mid-western Hill 43.0 10.0 4.3 2.6 8.9 3.4 3.3 2.8 2.6 0.0
Far-western Hill 16.9 9.5 1.5 10.4 4.7 0.0 0.0 0.0 0.0 2.3
Eastern Terai 16.5 10.1 14.8 6.2 6.8 1.8 0.6 2.4 2.1 2.7
Central Terai 39.7 3.8 4.8 4.2 0.0 0.0 0.9 1.6 1.6 3.6
Western Terai 21.1 4.2 4.3 2.0 8.8 0.7 1.0 0.0 0.0 0.0
Mid-western Terai 21.9 1.2 1.6 2.9 7.9 0.9 0.0 1.1 6.2 0.0
Far-western Terai 20.8 8.8 7.1 9.8 2.7 3.7 2.0 1.8 4.5 0.0
Total 32.7 9.7 7.5 6.4 6.2 1.4 1.3 2.0 2.8 2.6

1
The repetition rate is the percentage of students in a given grade in the previous school year who are
repeating that grade in the current school year.
2
The dropout rate is the percentage of students in a given grade in the previous school year who are not
attending school.



Household Population and Housing Characteristics * 19
Repetition among rural children is higher than among urban children at all grade levels.
However, after grade one, rural children are less likely to drop out than urban children. With the
exception of grade one, children from the mountain ecological zone are more likely repeat a grade at
every level. Differentials in the dropout rate by ecological zone are small.

Figure 2.3 shows the percentage of the de jure household population age 5-24 years attending
school by age and sex. The age-specific attendance rate indicates participation in school at any level
from primary to higher levels of education. Only 40 percent of girls and 47 percent of boys are
attending school at age five, indicating that a majority of children in Nepal at that age have not
entered the school system. The minimum official age for school attendance is six years. A higher
proportion of males than females attend school at every age, but this difference is significantly higher
after age ten. School attendance drops substantially after age 15 for females and after age 17 for
males. This sudden drop may be partly due to lack of financial resources to continue schooling and
partly due to the need to work to support the family.

Figure 2.3 Age-Specific School Attendance Rates
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 21 21 22 23 24
Age
0
20
40
60
80
100
Percent
Male
Female
Nepal 2001
Note: Figure shows percentage of the de jure household
population age 5-24 years attending school.

2.4 HOUSING CHARACTERISTICS

The physical characteristics of households are important in assessing the general
socioeconomic condition of the population. In the 2001 NDHS, respondents were asked about access
to electricity, sources of drinking water and time taken to the nearest source, type of toilet facility,
main material of the floor, and type of cooking fuel.

20 * Household Population and Housing Characteristics
Table 2.6 provides information on selected housing characteristics by residence. Overall, 25
percent of households have electricity. This is a 37 percent increase over the last five years according
to data obtained in the 1996 NFHS. There is a considerable difference between urban and rural
households in the availability of electricity. Eighty-six percent of urban households have electricity,
compared with only 17 percent of rural households.


Table 2.6 Housing characteristics
Percent distribution of households by background characteristics,
according to residence, Nepal 2001


Residence


Background
characteristic Urban Rural Total
Electricity
Yes 85.7 17.4 24.6
No 14.3 82.6 75.4

Total 100.0 100.0 100.0

Source of drinking water
Piped water 55.2 33.0 35.4
Dug well 10.9 3.8 4.6
Tubewell/borehole 30.8 38.1 37.4
Surface water 3.1 24.9 22.7

Total 100.0 100.0 100.0

Time to water source
Percentage <15 minutes 93.0 74.1 76.1
Median time to source 0.0 4.8 4.6

Sanitation facility
Flush toilet 58.3 6.1 11.5
Traditional pit toilet 14.6 17.1 16.8
Ventilated/improved pit latrine 7.0 1.5 2.1
No facility/bush/field 20.1 75.3 69.5
Other 0.1 0.1 0.1

Total 100.0 100.0 100.0

Type of cooking fuel
Firewood, charcoal, dung 39.1 94.1 88.3
Biogas 3.5 1.5 1.7
LPG gas 20.5 0.6 2.7
Electricity 0.3 0.0 0.1
Kerosene 35.8 2.3 5.8
Other 0.8 1.5 1.4

Total 100.0 100.0 100.0

Flooring material
Earth, mud, dung 34.4 91.7 85.7
Wood planks 4.9 2.7 2.9
Linoleum, carpet 16.3 0.6 2.3
Ceramic tiles, marble chips 1.1 0.0 0.1
Cement 42.2 4.6 8.5
Other 1.1 0.3 0.4

Total 100.0 100.0 100.0
Number of households 900 7,702 8,602
Note: Total includes households for which information on flooring
material is missing.




Household Population and Housing Characteristics * 21
Information on the source of drinking water and accessibility to the source was also collected
in the 2001 NDHS. Safe drinking water is important for health and sanitation. Table 2.6 shows that
only 35 percent of households (55 percent in urban areas and 33 percent in rural areas) have access to
piped drinking water, a small increase from the1996 level. Tubewells and boreholes are the major
source of drinking water used by 37 percent of households; this source is important for both urban
and rural households (31 percent and 38 percent, respectively). One-fourth of households in rural
areas reported surface water as their main source of drinking water. Households with no access to
drinking water within their own premises were also asked about the time required to fetch water.
Overall, 76 percent of households have access to water within 15 minutes. As expected, there is
better access to water in urban areas than in rural areas.

The majority of households (70 percent) do not have sanitation facilities. Lack of sanitation
facilities is more common in rural areas (75 percent) than in urban areas (20 percent). Nineteen
percent of households have a traditional pit toilet or ventilated/improved pit latrine (22 percent in
urban areas and 19 percent in rural areas). Twelve percent of households have flush toilets, which are
predominantly located in urban households (58 percent).

Traditional fuels such as firewood, charcoal, and dung are the most commonly used
(88 percent) type of cooking fuel in Nepal (39 percent in urban areas and 94 percent in rural areas).
Use of kerosene and gas for cooking is only common in urban households (36 percent and 21
percent, respectively). Smoke inhalation from burning firewood, charcoal, or dung during the process
of cooking is one of the common causes of respiratory illnesses among women. The 2001 NDHS
collected information on the number of households that have improved smokeless chulos, that is,
households with a fireplace that has an outlet for the smoke to escape. Only 1 percent of households
using firewood, charcoal, or dung have improved smokeless chulos (data not shown).

Most households (86 percent) have earth, mud,
or dung floors. Such traditional floors are almost
universal in rural households (92 percent), while one in
three urban households has this type of flooring. Nine
percent of all households have a cement floor, which is
more common in urban households (42 percent) than in
rural households (5 percent).

Information on the possession of various durable
goods was also collected at the household level. Table
2.7 shows that overall, 44 percent of households have
radios, one-fourth have bicycles, 13 percent have
televisions, and 3 percent have telephones. There is a
vast difference between urban and rural households,
with urban households much more likely to own these
consumer durable items than rural households. The
urban-rural difference is especially pronounced for ownership of televisions and telephones. Overall,
the possession of these items has increased over the last five years; this is reflected in the decrease in
the percentage that possesses none of these items from 53 percent in 1996 to 42 percent in 2001.



Table 2.7 Household durable goods
Percentage of households possessing various
durable consumer goods, by residence, Nepal
2001


Residence

Durable consumer
goods Urban Rural Total


Radio 61.0 41.4 43.5
Television 58.9 7.7 13.1
Telephone 18.0 0.6 2.5
Bicycle 44.0 24.0 26.1

None of the above 17.0 44.9 42.0

Number of households 900 7,702 8,602
Respondents Characteristics and Status * 23
3
RESPONDENTS CHARACTERISTICS
AND STATUS


The purpose of this chapter is to provide a descriptive summary of the demographic and
socioeconomic characteristics of the individual respondents in the 2001 Nepal Demographic and
Health Survey (NDHS). Information on the basic characteristics of women and men interviewed in
the survey is essential for the interpretation of the findings and serves as an approximate indicator of
the representativeness of the survey. It also provides valuable input for social and economic
development planning.

3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS

Table 3.1 shows the distribution of respondents by selected background characteristics
including age, marital status, residence, region, education, religion, and caste. Respondents are ever-
married women age 15-49 and ever-married men age 15-59 who slept in a selected household the
night before the interview.

Relatively high proportions of respondents are in the younger age groups, with almost half of
them under age 30. The proportion of eligible women declines after age 25-29. This is true of
eligible men as well, with the proportion of eligible men declining after age 30-34. Respondents are
mostly concentrated in the age group 20-39. The age distribution of ever-married women in the 2001
NDHS is consistent with the age distribution in the 1996 NFHS (Pradhan et al., 1997).

The majority of women and men are currently married with a very small minority divorced,
separated, or widowed. Most respondents (90 percent) live in rural areas. One in two respondents
lives in the terai, two in five in the hills, and 7 percent in the mountains.

The distribution of respondents by development region shows that one-third are from the
Central region, one-quarter are from the Eastern region, one-fifth are from the Western region, and
about one in ten each is from the Mid-western and Far-western regions. The subregional distribution
shows the highest concentration of eligible women and men in the Central terai subregion
(19 percent and 18 percent, respectively), followed by the Eastern terai (16 percent and 17 percent,
respectively) and the Central and Western hill subregions (about 10 to 12 percent each). In each of
the remaining subregions, the proportion of women and men is less than 10 percent.

Men are much more educated than women. Nearly three in four women and two in five men
have never attended school. Fifteen percent of women and 30 percent of men have some primary
education only, while 9 percent of women and 20 percent of men have some secondary education,
and 4 percent of women and 13 percent of men have completed their School Leaving Certificate
(SLC).

Most respondents are Hindu (about 85 percent), 7 percent of women and 9 percent of men are
Buddhist, and 5 percent of respondents are Muslim. One in five respondents belongs to the
occupational caste group, which is designated on the basis of the type of work done (with
blacksmiths, tailor, cobbler, sweeper, laundry man, etc. being the most prominent in the rural
settings). The Chettris make up about 17 percent of the population and the Brahmins comprise
13 percent.
24 * Respondents Characteristics and Status

Table 3.1 Background characteristics of respondents


Percent distribution of women and men by selected background characteristics, Nepal 2001


Number of women Number of men


Background
characteristic
Weighted
percent Weighted Unweighted
Weighted
percent Weighted Unweighted


Age


15-19 10.8 941 916 3.1 70 70


20-24 19.0 1,658 1,651 13.0 295 291


25-29 19.1 1,666 1,646 15.0 340 334


30-34 16.4 1,427 1,458 15.2 344 343


35-39 13.4 1,168 1,184 14.2 322 329


40-44 11.8 1,030 1,021 11.5 261 267


45-49 9.6 837 850 10.7 243 239


50-54 na na na 9.6 216 219


55-59 na na na 7.6 171 169





Marital status


Married 95.6 8,342 8,324 97.2 2,198 2,193


Divorced/separated 1.5 132 142 0.8 17 19


Widowed 2.9 252 260 2.0 46 49





Residence


Urban 9.6 841 1,154 10.0 227 304


Rural 90.4 7,885 7,572 90.0 2,034 1,957





Ecological zone


Mountain 6.9 602 1,188 6.7 151 307


Hill 41.4 3,615 3,243 39.6 896 793


Terai 51.7 4,509 4,295 53.7 1,214 1,161





Development region


Eastern 24.0 2,098 2,068 25.8 583 570


Central 32.1 2,804 2,392 33.2 750 633


Western 20.3 1,771 1,556 19.3 436 390


Mid-western 13.7 1,197 1,142 13.0 295 293


Far-western 9.8 855 1,568 8.7 197 375





Subregion


Eastern Mountain 1.4 126 330 1.5 33 86


Central Mountain 2.4 209 395 2.6 59 117


Western Mountain 3.1 267 463 2.6 59 104


Eastern Hill 6.6 580 528 7.1 161 147


Central Hill 10.8 945 873 12.3 278 238


Western Hill 12.3 1,075 851 10.4 235 182


Mid-western Hill 7.4 648 395 6.3 143 91


Far-western Hill 4.2 368 596 3.5 80 135


Eastern Terai 16.0 1,393 1,210 17.2 389 337


Central Terai 18.9 1,651 1,124 18.3 413 278


Western Terai 8.0 696 705 8.9 201 208


Mid-western Terai 5.0 438 554 5.6 126 155


Far-western Terai 3.8 331 702 3.7 85 183





Education


No education 72.0 6,279 6,269 37.7 852 846


Primary 14.8 1,294 1,274 29.7 670 674


Some secondary 9.3 814 832 20.0 452 455


SLC and above 3.9 339 351 12.7 287 286





Religion


Hindu 85.5 7,462 7,485 84.1 1,902 1,918


Buddhist 7.1 621 660 8.5 193 196


Muslim 4.7 407 355 4.6 104 87


Christian 0.7 60 54 0.7 15 14


Other 2.0 177 172 2.0 46 46





Caste/ethnic group


Brahmin 12.8 1,117 1,122 13.0 295 292


Chhetri/Thakuri/Rajput 17.8 1,553 1,831 17.0 384 440


Newar 4.8 421 424 5.2 117 116


Gurung 1.3 116 110 1.1 25 24


Magar 6.9 600 524 5.9 133 121


Tamang/Sherpa 6.2 542 564 7.2 164 160


Rai/Limbu 4.7 408 456 4.8 107 120


Muslim/Churaute 4.6 405 354 4.6 104 87


Tharu/Rajbanshi 6.9 598 708 8.1 184 218


Yadav/Ahir 3.2 279 220 4.0 90 72


Occupational 21.1 1,840 1,722 20.0 452 441


Other hill origin 2.6 223 198 2.7 61 51


Other terai origin 7.1 623 493 6.4 145 119





Total 100.0 8,726 8,726 100.0 2,261 2,261


Note: Education categories refer to the highest level of education attended, whether or not that level was completed.
SLC = School Leaving Certificate


Respondents Characteristics and Status * 25


3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS

Tables 3.2.1 and 3.2.2 show the educational level of female and male respondents by selected
background characteristics. The median years of schooling for men is 2.5 years, and it is close to 0
for women (the median for women is not shown because more than 50 percent of women in most of
the categories have no education and, therefore, a median of less than 1 year of schooling).


Table 3.2.1 Educational attainment of women
Percent distribution of women by highest level of schooling attended or completed, according to background characteristics,
Nepal 2001



Highest level of schooling attended or completed



Background
characteristic
No
education
Some
primary
Completed
primary
1

Some
secondary
Completed
secondary
2

More than
secondary Total
Number
of
women


Age
15-19 52.2 20.2 5.9 18.5 2.8 0.4 100.0 941
20-24 59.2 13.6 4.6 15.6 4.7 2.3 100.0 1,658
25-29 67.8 12.8 3.5 9.8 4.5 1.7 100.0 1,666
30-34 74.2 11.2 2.8 8.5 2.1 1.2 100.0 1,427
35-39 83.9 8.2 1.6 4.5 1.1 0.7 100.0 1,168
40-44 86.8 7.7 1.8 2.7 0.6 0.4 100.0 1,030
45-49 88.9 6.6 1.2 2.1 0.7 0.6 100.0 837

Residence
Urban 42.9 14.7 4.5 23.9 8.3 5.6 100.0 841
Rural 75.1 11.4 3.0 7.8 2.1 0.7 100.0 7,885

Ecological zone
Mountain 81.1 10.5 1.7 4.7 1.6 0.4 100.0 602
Hill 67.0 14.4 3.8 10.4 3.0 1.4 100.0 3,615
Terai 74.7 9.6 2.8 9.1 2.5 1.2 100.0 4,509

Development region
Eastern 67.0 12.7 3.8 12.0 3.0 1.5 100.0 2,098
Central 74.6 11.3 2.6 7.2 3.0 1.4 100.0 2,804
Western 62.0 15.4 4.5 13.3 3.3 1.5 100.0 1,771
Mid-western 80.1 8.6 2.2 6.9 1.7 0.6 100.0 1,197
Far-western 84.8 6.9 2.0 5.1 1.1 0.1 100.0 855

Subregion
Eastern Mountain 57.9 19.1 3.9 13.3 4.8 0.9 100.0 126
Central Mountain 80.3 14.2 1.5 2.5 1.0 0.5 100.0 209
Western Mountain 92.7 3.7 0.9 2.4 0.4 0.0 100.0 267
Eastern Hill 67.2 16.9 5.4 8.4 1.1 1.0 100.0 580
Central Hill 63.8 14.9 2.7 10.7 5.1 2.8 100.0 945
Western Hill 53.1 18.7 5.7 16.8 4.0 1.6 100.0 1,075
Mid-western Hill 81.6 9.8 2.1 4.9 1.6 0.0 100.0 648
Far-western Hill 89.6 4.6 1.7 3.8 0.5 0.0 100.0 368
Eastern Terai 67.7 10.4 3.1 13.4 3.6 1.8 100.0 1,393
Central Terai 80.1 8.9 2.6 5.7 2.0 0.7 100.0 1,651
Western Terai 75.6 10.2 2.7 7.8 2.2 1.4 100.0 696
Mid-western Terai 73.7 8.6 2.7 11.1 2.1 1.7 100.0 438
Far-western Terai 76.9 10.4 2.8 7.7 1.9 0.3 100.0 331

Total 72.0 11.7 3.1 9.3 2.7 1.2 100.0 8,726

1
Completed grade 5 at the primary level
2
Completed grade 10 at the secondary level


26 * Respondents Characteristics and Status





Table 3.2.2 Educational attainment of men
Percent distribution of men by highest level of schooling attended or completed, and median number of years of schooling,
according to background characteristics, Nepal 2001



Highest level of schooling attended or completed



Background
characteristic
No
education
Some
primary
Completed
primary
1

Some
secondary
Completed
secondary
2

More than
secondary Total
Number
of
men
Median
years of
schooling

Age
15-19 14.0 24.3 23.5 33.6 4.7 0.0 100.0 70 4.5
20-24 13.9 23.3 13.8 35.0 9.8 4.3 100.0 295 4.9
25-29 23.2 24.1 6.7 28.8 9.1 8.2 100.0 340 4.4
30-34 34.4 20.4 7.1 20.2 10.6 7.2 100.0 344 3.3
35-39 37.3 23.1 8.5 17.8 6.8 6.5 100.0 322 2.0
40-44 44.4 23.9 6.5 13.7 5.5 6.0 100.0 261 1.1
45-49 45.1 20.8 9.0 15.1 5.1 5.1 100.0 243 1.0
50-54 58.9 17.3 5.8 9.8 3.9 4.3 100.0 216 0.0
55-59 77.0 10.6 4.1 4.2 2.0 2.1 100.0 171 0.0

Residence
Urban 20.7 14.8 7.0 25.5 14.4 17.6 100.0 227 6.8
Rural 39.6 22.0 8.5 19.4 6.3 4.3 100.0 2,034 2.1

Ecological zone
Mountain 44.6 27.2 5.9 14.1 6.0 2.3 100.0 151 0.4
Hill 30.7 25.6 8.4 21.7 7.4 6.2 100.0 896 3.2
Terai 41.9 17.3 8.7 19.5 7.0 5.6 100.0 1,214 2.1

Development region
Eastern 37.9 20.0 7.0 21.7 8.2 5.2 100.0 583 2.3
Central 40.9 20.3 9.2 14.9 6.9 7.9 100.0 750 2.1
Western 29.9 24.0 9.8 22.9 8.1 5.3 100.0 436 3.4
Mid-western 41.0 20.2 4.6 25.3 5.5 3.4 100.0 295 2.0
Far-western 37.0 24.2 12.2 19.9 4.6 2.0 100.0 197 2.4

Subregion
Eastern Mountain 33.7 19.8 10.5 20.9 9.3 5.8 100.0 33 3.0
Central Mountain 44.4 32.5 3.4 13.7 4.3 1.7 100.0 59 0.1
Western Mountain 51.0 26.0 5.8 10.6 5.8 1.0 100.0 59 0.0
Eastern Hill 34.9 28.7 6.2 21.2 6.2 3.0 100.0 161 1.9
Central Hill 30.4 24.8 8.1 16.8 7.9 12.0 100.0 278 3.3
Western Hill 28.0 23.7 11.1 21.4 9.4 6.4 100.0 235 3.8
Mid-western Hill 29.1 28.5 3.4 31.8 5.6 1.6 100.0 143 3.1
Far-western Hill 33.9 23.0 14.7 22.5 5.3 0.5 100.0 80 2.6
Eastern Terai 39.5 16.4 7.0 22.0 8.9 6.1 100.0 389 2.4
Central Terai 47.4 15.6 10.7 13.7 6.5 6.0 100.0 413 1.2
Western Terai 32.0 24.5 8.2 24.6 6.6 4.1 100.0 201 2.8
Mid-western Terai 49.7 12.3 6.0 21.0 4.7 6.3 100.0 126 0.0
Far-western Terai 38.7 20.4 11.8 21.0 4.4 3.6 100.0 85 2.8

Total 37.7 21.3 8.4 20.0 7.1 5.6 100.0 2,261 2.5

1
Completed grade 5 at the primary level
2
Completed grade 10 at the secondary level


Respondents Characteristics and Status * 27




As expected, level of education decreases with increasing age, reflecting an improvement in
educational attainment over time. The urban-rural difference in education is marked and is relatively
wider among men than among women. Two-fifths (43 percent) of women in urban areas have no
education, compared with three-fourths of rural women. Twice as many rural men as urban men
have no education. The urban advantage is especially obvious at higher levels of education for
women but not for men. For example, although the urban-rural difference among women who have
only some secondary education is 16 percentage points, it is 6 percentage points among men.

Women and men residing in the mountain ecological zone are least educated, while those
residing in the hill zone are most educated. One-third of women and two-thirds of men residing in
the hills have some education. Women residing in the Western region are more likely to have some
education than women residing in the other regions, while those residing in the Far-western region
are the least educated. Similarly, men residing in the Western region are most likely to be educated,
while men residing in the Central and Mid-western regions are the least educated. Educational
differences by subregions are marked. The proportion of women who have never attended school
ranges from a low of 53 percent in the Western hill subregion to a high of 93 percent in the Western
mountain subregion. The proportion of men having no education ranges from 28 percent in the
Western hill subregion to 51 percent in the Western mountain subregion, indicating similar patterns
for both men and women. In the Central hill subregion, 8 percent of women and 20 percent of men
completed at least secondary education, which is highest among all subregions.

3.3 LITERACY

In the 2001 NDHS, literacy was determined by a respondents ability to read part or all of a
sentence in any language that the respondent knew. The questions assessing literacy were asked only
of respondents who had not attended school or who attended primary school only. Literacy is widely
acknowledged as benefiting both the individual and society and is associated with a number of
positive outcomes for health, nutrition, and status of both men and women.

Tables 3.3.1 and 3.3.2 show that men are twice as likely to be literate as women (70 percent
and 35 percent, respectively). As expected, literacy is much lower among rural women and men than
among those living in the urban areas. A higher proportion of women (43 percent) and men
(79 percent) living in the hill ecological zone are literate, compared with those in the mountain and
terai zones. Women living in the Western development region and men living in the Western and
Mid-western regions are more likely to be literate than those living in the other development regions.
The percentage of literate women is highest in the Western hill subregion (62 percent), while literacy
is highest among men residing in the Mid-western hill subregion (87 percent).

Nepal has an active literacy program. Consequently, the 2001 NDHS added a question to
ascertain the proportion of women and men who have attended a literacy program. Tables 3.3.1 and
3.3.2 show that women are much more likely to have participated in a literacy program than men,
with 19 percent of women and 5 percent of men having done so.
28 * Respondents Characteristics and Status



Table 3.3.1 Literacy of women
Percent distribution of women by level of schooling attended and by level of literacy, percent literate, and percentage who have
participated in a literacy program, according to background characteristics, Nepal 2001


Primary school or no schooling


Background
characteristic
Secondary
school or
higher
Can read a
whole
sentence
Can read
part of a
sentence
Cannot
read
at all
No card
with
required
language Total
Number
of
women
Percent
literate
1

Percent who
have
participated
in a literacy
program


Age
15-19 21.7 21.6 9.0 47.2 0.5 100.0 941 52.3 19.4
20-24 22.6 18.7 7.1 51.4 0.2 100.0 1,658 48.4 20.2
25-29 15.9 16.8 7.0 60.2 0.1 100.0 1,666 39.7 19.5
30-34 11.8 16.3 7.4 64.1 0.3 100.0 1,427 35.5 21.8
35-39 6.3 11.8 4.5 77.1 0.2 100.0 1,168 22.7 18.7
40-44 3.7 11.3 5.6 79.1 0.2 100.0 1,030 20.7 16.3
45-49 3.3 7.8 5.6 83.3 0.0 100.0 837 16.7 16.3

Residence
Urban 37.9 18.7 7.4 35.8 0.2 100.0 841 64.0 13.8
Rural 10.6 15.1 6.6 67.5 0.2 100.0 7,885 32.2 19.8

Ecological zone
Mountain 6.6 10.9 6.5 76.0 0.0 100.0 602 24.0 22.1
Hill 14.8 20.4 8.1 56.7 0.0 100.0 3,615 43.2 25.2
Terai 12.8 12.0 5.6 69.2 0.4 100.0 4,509 30.5 14.0

Development region
Eastern 16.5 15.4 6.3 61.4 0.5 100.0 2,098 38.1 14.7
Central 11.5 10.5 5.9 72.1 0.0 100.0 2,804 27.9 14.5
Western 18.1 26.9 5.9 48.8 0.3 100.0 1,771 50.9 26.9
Mid-western 9.2 12.9 10.4 67.4 0.1 100.0 1,197 32.4 25.7
Far-western 6.3 11.5 6.6 75.6 0.0 100.0 855 24.4 21.0

Subregion
Eastern Mountain 19.1 20.9 9.7 50.3 0.0 100.0 126 49.7 17.0
Central Mountain 4.1 13.4 8.4 74.2 0.0 100.0 209 25.8 35.9
Western Mountain 2.8 4.3 3.5 89.4 0.0 100.0 267 10.6 13.6
Eastern Hill 10.5 21.2 7.2 61.1 0.0 100.0 580 38.9 21.0
Central Hill 18.6 16.9 8.2 56.1 0.1 100.0 945 43.7 23.0
Western Hill 22.4 31.7 7.5 38.4 0.0 100.0 1,075 61.6 30.5
Mid-western Hill 6.6 11.8 10.7 70.9 0.0 100.0 648 29.1 26.8
Far-western Hill 4.2 10.1 5.8 79.9 0.0 100.0 368 20.1 19.4
Eastern Terai 18.8 12.4 5.6 62.5 0.7 100.0 1,393 36.7 11.8
Central Terai 8.4 6.4 4.3 80.9 0.0 100.0 1,651 19.1 6.9
Western Terai 11.5 19.6 3.4 64.9 0.7 100.0 696 34.4 21.3
Mid-western Terai 15.0 16.4 11.5 56.7 0.4 100.0 438 42.9 26.2
Far-western Terai 9.9 16.6 9.3 64.2 0.0 100.0 331 35.8 27.3

Total 13.2 15.4 6.7 64.5 0.2 100.0 8,726 35.3 19.2

1
Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence

Respondents Characteristics and Status * 29




Table 3.3.2 Literacy of men
Percent distribution of men by level of schooling attended and by level of literacy, percent literate, and percentage who have
participated in a literacy program, according to background characteristics, Nepal 2001


Primary school or no schooling


Background
characteristic
Secondary
school or
higher
Can read a
whole
sentence
Can read
part of a
sentence
Cannot
read
at all
No card
with
required
language Total
Number
of
men
Percent
literate
1

Percent
who have
participated
In a literacy
program

Age
15-19 38.3 37.2 7.9 16.6 0.0 100.0 70 83.4 2.2
20-24 49.0 28.9 6.6 15.5 0.0 100.0 295 84.5 3.0
25-29 46.1 22.6 7.6 23.7 0.0 100.0 340 76.3 3.6
30-34 38.0 22.8 9.2 29.7 0.2 100.0 344 70.1 4.2
35-39 31.1 27.5 6.4 34.5 0.4 100.0 322 65.1 5.6
40-44 25.1 31.3 12.4 31.1 0.0 100.0 261 68.9 5.9
45-49 25.2 31.0 5.7 38.1 0.0 100.0 243 61.9 5.5
50-54 18.1 32.4 12.8 36.1 0.6 100.0 216 63.3 9.1
55-59 8.3 31.0 13.5 47.1 0.0 100.0 171 52.9 8.7

Residence
Urban 57.5 19.6 8.5 14.4 0.0 100.0 227 85.6 3.4
Rural 29.9 29.0 8.9 32.0 0.2 100.0 2,034 67.8 5.4

Ecological zone
Mountain 22.3 30.9 11.1 35.7 0.0 100.0 151 64.3 6.9
Hill 35.3 36.0 7.9 20.5 0.3 100.0 896 79.2 4.9
Terai 32.0 21.9 9.3 36.7 0.1 100.0 1,214 63.2 5.3

Development region
Eastern 35.1 23.1 9.3 32.5 0.0 100.0 583 67.5 3.6
Central 29.6 29.1 6.6 34.7 0.0 100.0 750 65.3 6.1
Western 36.3 32.1 7.6 23.4 0.6 100.0 436 76.0 5.6
Mid-western 34.2 28.2 13.5 23.8 0.3 100.0 295 75.9 7.1
Far-western 26.6 30.1 12.0 31.4 0.0 100.0 197 68.6 2.9

Subregion
Eastern Mountain 36.0 31.4 8.1 24.4 0.0 100.0 33 75.6 4.7
Central Mountain 19.7 40.2 9.4 30.8 0.0 100.0 59 69.2 11.1
Western Mountain 17.3 21.2 14.4 47.1 0.0 100.0 59 52.9 3.8
Eastern Hill 30.3 30.8 10.3 28.7 0.0 100.0 161 71.3 2.7
Central Hill 36.7 37.2 7.0 19.1 0.0 100.0 278 80.9 5.3
Western Hill 37.2 36.7 6.6 18.4 1.1 100.0 235 80.5 5.8
Mid-western Hill 39.0 39.7 7.8 13.5 0.0 100.0 143 86.5 6.7
Far-western Hill 28.4 33.7 10.9 27.1 0.0 100.0 80 72.9 1.3
Eastern Terai 37.1 19.2 9.1 34.7 0.0 100.0 389 65.3 3.9
Central Terai 26.3 22.1 5.9 45.7 0.0 100.0 413 54.3 5.9
Western Terai 35.3 26.8 8.7 29.2 0.0 100.0 201 70.8 5.4
Mid-western Terai 32.0 19.2 19.7 28.4 0.7 100.0 126 70.9 7.6
Far-western Terai 29.1 26.1 12.2 32.7 0.0 100.0 85 67.3 4.8

Total 32.7 28.1 8.9 30.2 0.2 100.0 2,261 69.6 5.2

1
Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence

30 * Respondents Characteristics and Status



3.4 EXPOSURE TO MASS MEDIA

The 2001 NDHS collected information on the exposure of respondents to both the broadcast
and print media. Women were asked whether they usually read a newspaper or magazine at least
once a week, listen to the radio daily, and watch television at least once a week. This information is
important because it provides some indication of the extent to which Nepalese women are exposed to
family planning and health messages in the mass media. As shown in Table 3.4.1, only 7 percent of
women read a newspaper or magazine at least once a week, 23 percent watch television at least once
a week, and 39 percent listen to the radio daily. Only 4 percent of women are exposed to all three
media, and 51 percent have no access to any of the three media. Data from the 1996 NFHS show that
there has been considerable improvement in womens exposure to the media over the last five years.
For example, exposure to television nearly doubled between 1996 and 2001, from 12 percent to
23 percent. During the same period, the percentage of women not exposed to any of the three media
declined from 59 percent in 1996 to 51 percent in 2001. Generally, men have more exposure to the
mass media than women (Table 3.4.2). Thirteen percent of men are exposed to all three media, and
only 32 percent of men have no access to any of the three media. The radio is the most common
media source for both women and men.

Exposure to the media does not vary much by womens age. In the case of men, exposure to
mass media is highest among those age 20-24.

Urban women and men have greater exposure to all types of media than rural women and
men. In urban areas, 50 percent of women listen to the radio daily, 77 percent watch television at
least once a week, and 28 percent read a newspaper or magazine at least once a week, while the
corresponding data for rural women are 37 percent, 18 percent, and 5 percent, respectively. A
similar pattern is observed for men. Irrespective of the region, the level of exposure of respondents
to radio broadcasts is greater than to all other media sources, except in the Central terai subregion for
women and the Eastern terai and Central terai subregions for men, where weekly television exposure
is greater than daily radio exposure. Access to media sources is lowest in the mountain ecological
zone, the Far-western development region and the Western mountain subregion for both women and
men.

Not surprisingly, media exposure is highly related to the educational level of respondents.
Three-fifths of women and half of men with no education have no exposure to the mass media in
contrast to 5 percent of women and 4 percent of men who have completed their School Leaving
Certificate (SLC). Educated women and men also have greater access to all three media sources.
Whereas 36 percent of women and 49 percent of men who have completed their SLC are exposed to
all three media sources, women and men with no education have almost no exposure. Less educated
women and men are more likely to be exposed to the radio than to other media, but even then, only
one in three women and two in five men with no education listen to the radio daily. The lower level
of exposure to the media among uneducated women and men, who are also more likely to be poor,
may be because they cannot afford radios, televisions, and newspapers.

Respondents Characteristics and Status * 31


Table 3.4.1 Exposure to mass media: women
Percentage of women who usually read a newspaper at least once a week, watch television at least once a
week, and listen to the radio every day, by background characteristics, Nepal 2001


Background
characteristic
Reads a
newspaper
at least
once a
week
Watches
television at
least once a
week
Listens to
the radio
every day
All three
media No media
Number
of
women


Age
15-19 10.3 21.9 41.8 3.8 48.2 941
20-24 9.6 25.2 40.3 4.7 48.8 1,658
25-29 7.9 23.4 36.6 4.4 52.4 1,666
30-34 8.0 23.8 40.9 5.0 49.0 1,427
35-39 4.7 21.9 36.1 2.5 53.6 1,168
40-44 3.9 22.1 35.8 2.3 53.9 1,030
45-49 3.9 22.0 38.6 3.0 52.5 837

Residence
Urban 28.0 76.5 50.3 17.2 14.3 841
Rural 5.0 17.5 37.4 2.4 55.0 7,885

Ecological zone
Mountain 2.4 4.4 33.6 1.2 64.8 602
Hill 8.8 17.2 48.3 4.3 46.1 3,615
Terai 6.5 30.5 31.5 3.8 53.2 4,509

Development region
Eastern 9.2 35.7 48.3 5.5 38.6 2,098
Central 8.0 26.1 28.5 4.7 57.7 2,804
Western 7.7 20.2 46.1 3.3 45.1 1,771
Mid-western 4.9 8.9 41.0 2.3 55.6 1,197
Far-western 2.0 8.9 29.2 0.6 65.6 855

Subregion
Eastern Mountain 8.2 12.4 52.7 4.5 44.5 126
Central Mountain 1.8 5.1 33.2 0.8 64.3 209
Western Mountain 0.2 0.2 24.8 0.0 74.7 267
Eastern Hill 7.4 16.9 52.3 2.3 42.5 580
Central Hill 17.8 35.8 49.5 10.9 37.9 945
Western Hill 8.5 15.9 58.8 3.3 36.7 1,075
Mid-western Hill 2.4 1.5 38.5 0.6 61.4 648
Far-western Hill 0.7 1.0 25.9 0.0 73.0 368
Eastern Terai 10.1 45.7 46.2 6.9 36.4 1,393
Central Terai 3.2 23.2 15.9 1.6 68.2 1,651
Western Terai 6.5 26.9 26.5 3.2 58.2 696
Mid-western Terai 9.8 22.0 49.8 5.2 40.9 438
Far-western Terai 4.1 21.7 33.7 1.5 54.6 331

Education
No education 0.7 14.5 30.9 0.2 61.7 6,279
Primary 9.4 33.2 50.3 4.7 34.5 1,294
Some secondary 32.1 55.0 64.9 17.0 14.0 814
SLC and above 60.5 68.7 73.8 35.8 5.2 339

Total 7.2 23.2 38.6 3.9 51.0 8,726

SLC = School Leaving Certificate

32 * Respondents Characteristics and Status



Table 3.4.2 Exposure to mass media: men
Percentage of men who usually read a newspaper at least once a week, watch television at least once
a week, and listen to the radio every day, by background characteristics, Nepal 2001


Background
characteristic
Reads a
newspaper
at least
once a
week
Watches
television at
least once a
week
Listens to
the radio
every day
All three
media No media
Number
of
men


Age
15-19 22.1 34.7 50.7 10.3 31.5 70
20-24 31.9 45.7 63.3 17.8 20.8 295
25-29 32.9 38.9 56.1 12.9 25.7 340
30-34 27.0 36.4 52.3 16.0 33.8 344
35-39 28.7 32.7 54.7 13.3 34.0 322
40-44 24.6 28.9 51.5 12.9 36.9 261
45-49 21.5 33.8 54.8 14.3 33.2 243
50-54 17.8 24.9 49.5 8.4 41.5 216
55-59 12.2 19.4 55.2 7.5 38.2 171

Residence
Urban 62.3 78.6 62.3 40.6 7.9 227
Rural 21.7 28.9 53.9 10.3 34.9 2,034

Ecological zone
Mountain 14.4 7.0 48.6 4.2 48.2 151
Hill 26.5 24.5 64.2 13.5 29.0 896
Terai 26.6 44.1 48.4 14.3 32.6 1,214

Development region
Eastern 28.3 44.1 54.3 15.3 29.2 583
Central 25.3 45.4 53.5 15.4 28.1 750
Western 30.3 25.7 56.1 14.6 34.0 436
Mid-western 20.6 9.9 57.6 6.5 39.7 295
Far-western 17.5 13.5 53.4 6.8 41.9 197

Subregion
Eastern Mountain 19.8 10.5 45.3 7.0 51.2 33
Central Mountain 16.2 12.0 63.2 6.8 32.5 59
Western Mountain 9.6 0.0 35.6 0.0 62.5 59
Eastern Hill 22.1 22.8 64.2 10.9 32.1 161
Central Hill 34.1 45.8 69.3 22.0 17.3 278
Western Hill 33.3 20.1 63.2 14.8 29.7 235
Mid-western Hill 13.9 3.8 59.6 3.8 40.4 143
Far-western Hill 11.9 4.3 58.2 3.0 40.5 80
Eastern Terai 31.6 55.8 50.9 17.8 26.1 389
Central Terai 20.7 50.0 41.5 12.2 34.7 413
Western Terai 26.8 32.2 47.8 14.3 38.9 201
Mid-western Terai 28.9 19.0 60.6 11.0 33.8 126
Far-western Terai 28.1 27.3 54.5 13.0 35.9 85

Education
No education 3.2 19.1 39.4 1.1 50.9 852
Primary 16.4 30.1 54.4 7.1 32.1 670
Some secondary 47.8 44.2 67.9 23.1 15.4 452
SLC and above 79.6 70.2 80.1 48.8 3.7 287

Total 25.8 33.9 54.7 13.3 32.2 2,261

SLC = School Leaving Certificate

Respondents Characteristics and Status * 33



3.5 EMPLOYMENT STATUS

In the 2001 NDHS, respondents were asked a number of questions about employment,
including whether they were currently working, and, if not, whether they had worked during the 12
months before the survey. Those who were currently working were then asked a number of
questions about the kind of work they were doing and whether they were paid in cash. Women who
earned cash for their work were asked who made the decision about how their earnings were used.

Table 3.5.1 and Figure 3.1 show current employment status by background characteristics of
women. Eighty-three percent of women were working at the time of the survey, 1 percent were not
currently employed but had worked in the 12 months prior to the survey, and 16 percent had not
worked in the 12 months prior to the survey.

The percentage currently employed rises with age from 71 percent among women age 15-19
to 89 percent among women age 40-49. Currently married women are less likely to be currently
employed than women who are divorced, separated, or widowed. The proportion of women currently
employed increases with the number of living children they have. Current employment is much
higher among rural women than among urban women (86 percent and 55 percent, respectively). The
proportion of women who are currently working is higher in the mountain ecological zone than in the
terai and hill zones. The proportion of women currently employed is much higher in the Far-western
development region than in the other regions. A similar pattern was observed in the 1996 NFHS.

In a relatively less industrialized country like Nepal, education is no guarantee for
employment. As observed in the 1996 NFHS, the 2001 NDHS also shows that the percentage of
women currently employed decreases with the level of education. For example, 87 percent of
women with no education are currently employed, compared with 56 percent of women with an
SLC. This is perhaps because employment opportunities are limited in the service sector, where
most educated persons seek employment, or because more educated women are wealthier and do not
have to work.

Table 3.5.2 shows employment information for men. Ninety-seven percent of men were
working at the time of the survey, 1 percent worked in the 12 months prior to the survey, and
2 percent had not worked in the 12 months preceding the survey.

Current employment is lowest among men age 15-19 because a relatively high percentage of
men in this age group are still studying (11 percent). There is no difference in the employment status
of men in the urban and rural areas. Similarly, there is hardly any difference in the employment
status of men by ecological zone, development region, and subregion, with the exception the
Western hills, where 8 percent of the men were not employed at the time of the survey. Unlike
women, ever-married men are equally likely to be employed, regardless of their educational
attainment.
34 * Respondents Characteristics and Status

Table 3.5.1 Employment status: women
Percent distribution of women by employment status, according to background characteristics,
Nepal 2001

Employed in the 12
months preceding the
survey


Background
characteristic
Currently
employed
Not
currently
employed
Not
employed in
the 12
months
preceding
the survey Total
Number
of
women

Age
15-19 71.0 0.8 28.1 100.0 941
20-24 74.2 1.8 24.0 100.0 1,658
25-29 83.1 1.5 15.5 100.0 1,666
30-34 88.3 1.0 10.7 100.0 1,427
35-39 88.0 1.2 10.8 100.0 1,168
40-44 89.1 0.7 10.1 100.0 1,030
45-49 88.7 1.0 10.3 100.0 837

Marital status
Married 82.5 1.2 16.3 100.0 8,342
Divorced/separated/widowed 91.5 1.5 7.1 100.0 384

Number of living children
0 73.9 1.3 24.8 100.0 1,051
1-2 78.5 1.5 20.0 100.0 3,101
3-4 86.3 0.9 12.8 100.0 3,016
5+ 91.0 1.1 7.9 100.0 1,557

Residence
Urban 55.4 2.4 42.2 100.0 841
Rural 85.8 1.1 13.1 100.0 7,885

Ecological zone
Mountain 97.1 0.7 2.2 100.0 602
Hill 92.0 1.1 7.0 100.0 3,615
Terai 73.7 1.4 25.0 100.0 4,509

Development region
Eastern 78.6 1.6 19.8 100.0 2,098
Central 74.8 1.3 23.9 100.0 2,804
Western 88.1 1.5 10.4 100.0 1,771
Mid-western 90.6 0.6 8.8 100.0 1,197
Far-western 98.0 0.2 1.8 100.0 855

Subregion
Eastern Mountain 94.2 0.6 5.2 100.0 126
Central Mountain 96.2 0.5 3.3 100.0 209
Western Mountain 99.1 0.9 0.0 100.0 267
Eastern Hill 96.6 0.2 3.2 100.0 580
Central Hill 83.7 1.7 14.6 100.0 945
Western Hill 89.9 1.8 8.2 100.0 1,075
Mid-western Hill 98.7 0.3 1.0 100.0 648
Far-western Hill 99.8 0.2 0.0 100.0 368
Eastern Terai 69.7 2.3 28.0 100.0 1,393
Central Terai 67.1 1.1 31.8 100.0 1,651
Western Terai 85.3 0.9 13.8 100.0 696
Mid-western Terai 76.6 0.8 22.6 100.0 438
Far-western Terai 95.0 0.3 4.7 100.0 331

Education
No education 86.6 1.1 12.4 100.0 6,279
Primary 79.9 1.1 19.0 100.0 1,294
Some secondary 70.3 1.8 27.9 100.0 814
SLC and above 55.9 2.7 41.4 100.0 339

Total 82.9 1.2 15.9 100.0 8,726
SLC = School Leaving Certificate


Respondents Characteristics and Status * 35

Table 3.5.2 Employment status : men
Percent distribution of men by employment status, and if not employed, their main activity during the 12 months preceding the
survey, according to background characteristics, Nepal 2001

Employed in the 12 months
preceding the survey

Not employed in the 12 months preceding the survey


Background
characteristic
Currently
employed
Not currently
employed
Going to
school/
studying
Looking
for work Inactive
Could not
work/
handicapped Other Total
Number
of
men

Age
15-19 89.1 0.0 10.9 0.0 0.0 0.0 0.0 100.0 70
20-24 95.7 1.3 2.9 0.0 0.0 0.0 0.1 100.0 295
25-29 97.7 1.1 0.0 0.8 0.4 0.0 0.0 100.0 340
30-34 97.9 0.8 0.0 0.0 0.4 0.6 0.4 100.0 344
35-39 97.9 1.9 0.0 0.0 0.2 0.0 0.0 100.0 322
40-44 98.7 0.4 0.0 0.0 0.0 0.9 0.0 100.0 261
45-49 95.8 1.4 0.0 0.6 0.4 1.9 0.0 100.0 243
50-54 95.2 2.4 0.0 0.0 0.4 2.0 0.0 100.0 216
55-59 93.4 1.0 0.0 0.0 2.0 3.6 0.0 100.0 171

Residence
Urban 96.6 1.5 0.3 0.0 1.1 0.4 0.1 100.0 227
Rural 96.6 1.2 0.8 0.2 0.3 0.9 0.1 100.0 2,034

Ecological zone
Mountain 97.2 0.5 1.0 0.0 0.3 1.0 0.0 100.0 151
Hill 96.2 1.7 0.7 0.3 0.3 0.8 0.0 100.0 896
Terai 96.8 1.0 0.7 0.1 0.4 0.9 0.1 100.0 1,214

Development region
Eastern 96.5 1.6 0.2 0.2 0.8 0.5 0.2 100.0 583
Central 97.4 0.3 0.7 0.2 0.1 1.3 0.0 100.0 750
Western 94.9 3.3 0.5 0.3 0.3 0.8 0.0 100.0 436
Mid-western 97.1 0.3 1.6 0.0 0.3 0.7 0.0 100.0 295
Far-western 96.8 0.5 1.4 0.0 0.3 0.8 0.2 100.0 197

Subregion
Eastern Mountain 95.3 2.3 0.0 0.0 1.2 1.2 0.0 100.0 33
Central Mountain 97.4 0.0 1.7 0.0 0.0 0.9 0.0 100.0 59
Western Mountain 98.1 0.0 1.0 0.0 0.0 1.0 0.0 100.0 59
Eastern Hill 98.6 0.7 0.7 0.0 0.0 0.0 0.0 100.0 161
Central Hill 98.4 0.3 0.0 0.5 0.3 0.5 0.0 100.0 278
Western Hill 91.7 5.6 0.0 0.6 0.6 1.5 0.0 100.0 235
Mid-western Hill 96.2 0.0 2.7 0.0 0.0 1.1 0.0 100.0 143
Far-western Hill 97.0 0.0 1.5 0.0 0.8 0.8 0.0 100.0 80
Eastern Terai 95.7 1.9 0.0 0.3 1.1 0.6 0.3 100.0 389
Central Terai 96.7 0.4 1.1 0.0 0.0 1.9 0.0 100.0 413
Western Terai 98.5 0.5 1.0 0.0 0.0 0.0 0.0 100.0 201
Mid-western Terai 98.0 0.7 0.7 0.0 0.7 0.0 0.0 100.0 126
Far-western Terai 96.0 1.2 1.2 0.0 0.0 1.2 0.4 100.0 85

Education
No education 96.7 1.2 0.0 0.0 0.4 1.7 0.0 100.0 852
Primary 98.1 0.9 0.1 0.2 0.0 0.8 0.0 100.0 670
Some secondary 94.7 2.2 2.2 0.0 0.9 0.0 0.1 100.0 452
SLC and above 95.5 0.8 2.1 0.9 0.3 0.0 0.4 100.0 287

Total 96.6 1.2 0.7 0.2 0.4 0.9 0.1 100.0 2,261

SLC = School Leaving Certificate
36 * Respondents Characteristics and Status
Figure 3.1 Employment Status of Women Age 15-49
Nepal 2001
Currently employed
83%
Not currently employed,
but worked in
last 12 months
1%
Did not work in
last 12 months
16%

3.6 OCCUPATION

Tables 3.6.1 and 3.6.2 show data on employed women and men by their current occupation
according to background characteristics. Agriculture is the dominant sector of the economy of Nepal.
More women than men are involved in this sector (91 percent and 64 percent, respectively). The
proportion of women in agricultural occupations reported in the 2001 NDHS is exactly the same as
that found in the 1991 Census (Central Bureau of Statistics, 1991) and the 1996 NFHS. Four percent
of employed women are in sales or service occupations. Men have more opportunities in the
nonagricultural sector, thus reducing their involvement in the agricultural sector. Eleven percent of
working men are involved in professional, technical, managerial, or clerical occupations.
Nine percent of men are involved in the sales and service sector, while another 9 percent work at
skilled manual jobs.

As expected, rural women are more likely than urban women to be employed in the
agricultural sector: 94 percent of rural women compared with 48 percent of urban women. The
pattern is similar for men, with 70 percent of rural working men employed in the agricultural sector,
compared with only 18 percent of urban men. About one-fifth of urban working women are in sales
and services and 15 percent are in skilled manual occupations. Some 33 percent of working men in
the urban areas are involved in the sales and service sector, compared with only 6 percent in the rural
areas. Respondents living in the mountain ecological zone are slightly more likely to be working in
the agricultural sector than those in the hill and terai zones. The highest proportion of women (one
in four) engaged in the nonagricultural sector is in the Central hill subregion. This is not surprising
since Kathmandu, the capital and largest urban center, is located there. There has been a slight
increase in the proportion of women involved in the nonagricultural sector when compared with data
from the 1996 NFHS.
Respondents Characteristics and Status * 37


Table 3.6.1 Occupation: women
Percent distribution of women employed in the 12 months preceding the survey by occupation, according to background
characteristics, Nepal 2001


Background
characteristic
Professional/
technical/
managerial Clerical
Sales and
services
Skilled
manual
Unskilled
manual Agriculture Total
Number
of
women

Age

15-19 1.2 0.2 1.9 2.1 0.4 94.1 100.0 676
20-24 1.8 0.6 4.5 2.5 0.3 90.3 100.0 1,260
25-29 2.0 0.1 4.5 3.0 0.4 89.9 100.0 1,408
30-34 2.5 0.6 5.4 2.4 0.8 88.3 100.0 1,274
35-39 1.1 0.7 3.7 2.2 0.5 91.7 100.0 1,041
40-44 1.7 0.3 4.9 1.6 0.8 90.8 100.0 926
45-49 0.7 0.4 4.7 1.1 0.0 92.9 100.0 750

Marital status
Married 1.7 0.4 4.2 2.2 0.4 91.1 100.0 6,979
Divorced/separated/
widowed 2.6 1.2 6.7 2.6 1.8 85.2 100.0 357

Number of living children
0 2.1 0.3 3.3 3.1 0.2 90.9 100.0 790
1-2 2.7 0.4 5.0 3.1 0.5 88.2 100.0 2,481
3-4 1.4 0.4 4.7 1.8 0.4 91.2 100.0 2,631
5+ 0.4 0.3 3.2 1.0 0.7 94.4 100.0 1,434

Residence
Urban 8.7 3.8 21.4 14.8 3.2 47.7 100.0 486
Rural 1.2 0.2 3.2 1.3 0.3 93.8 100.0 6,850

Ecological zone
Mountain 0.4 0.2 3.0 0.5 0.0 96.0 100.0 589
Hill 1.7 0.4 4.2 3.1 0.4 90.1 100.0 3,364
Terai 2.0 0.4 4.7 1.7 0.6 90.5 100.0 3,383

Development region
Eastern 1.8 0.5 6.0 2.4 0.9 88.4 100.0 1,683
Central 1.9 0.8 5.5 4.2 0.4 87.2 100.0 2,135
Western 1.9 0.2 4.2 1.1 0.6 92.0 100.0 1,587
Mid-western 1.8 0.1 2.7 1.0 0.2 94.2 100.0 1,092
Far-western 0.4 0.1 0.9 0.8 0.1 97.6 100.0 840

Subregion
Eastern Mountain 0.6 0.3 10.9 0.3 0.0 87.9 100.0 119
Central Mountain 0.5 0.3 1.8 0.0 0.0 97.4 100.0 202
Western Mountain 0.2 0.0 0.4 0.9 0.0 98.5 100.0 267
Eastern Hill 0.4 0.0 1.6 2.8 0.0 95.3 100.0 561
Central Hill 3.6 1.7 8.1 8.8 1.0 76.8 100.0 807
Western Hill 2.3 0.1 5.3 1.5 0.6 90.1 100.0 987
Mid-western Hill 0.4 0.0 1.8 0.3 0.0 97.6 100.0 641
Far-western Hill 0.1 0.0 1.0 0.1 0.2 98.6 100.0 368
Eastern Terai 2.8 0.7 7.8 2.4 1.5 84.6 100.0 1,003
Central Terai 0.9 0.3 4.3 1.6 0.0 92.9 100.0 1,126
Western Terai 1.2 0.3 2.3 0.4 0.5 95.2 100.0 600
Mid-western Terai 5.2 0.2 4.8 2.6 0.5 86.4 100.0 339
Far-western Terai 0.9 0.2 1.2 1.3 0.2 96.3 100.0 315

Education
No education 0.4 0.3 2.9 1.3 0.6 94.5 100.0 5,502
Primary 1.0 0.4 5.6 3.9 0.3 88.8 100.0 1,047
Some secondary 4.6 1.1 13.4 6.5 0.1 74.2 100.0 587
SLC and above 33.2 2.0 11.7 5.2 0.0 47.5 100.0 199

Total 1.7 0.4 4.4 2.2 0.5 90.8 100.0 7,336
SLC = School Leaving Certificate


38 * Respondents Characteristics and Status


Table 3.6.2 Occupation: men
Percent distribution of men employed in the 12 months preceding the survey by occupation, according to background characteristics, Nepal 2001

Background
characteristic
Professional/
technical/
managerial Clerical
Sales and
services
Skilled
manual
Unskilled
manual Agriculture
Don't know/
missing Total
Number
of
men

Age

15-19 0.0 0.0 9.3 23.0 13.2 53.6 0.9 100.0 62
20-24 3.2 5.3 8.3 12.7 11.6 58.9 0.0 100.0 286
25-29 4.9 6.3 9.3 10.6 9.5 59.3 0.0 100.0 336
30-34 7.1 5.1 12.2 7.8 6.8 61.1 0.0 100.0 340
35-39 7.3 6.8 9.3 8.3 6.6 61.7 0.0 100.0 321
40-44 7.1 6.8 7.9 7.9 6.1 64.2 0.0 100.0 258
45-49 7.8 1.5 8.1 8.1 6.6 67.9 0.0 100.0 236
50-54 4.5 4.5 6.5 4.8 3.8 75.9 0.0 100.0 211
55-59 4.1 0.6 6.4 7.1 1.3 80.6 0.0 100.0 161

Marital status
Married 5.9 4.9 8.8 9.0 7.1 64.2 0.0 100.0 2,151
Divorced/separated/
widowed

0.0

2.5

9.7

9.4

8.9

69.5

0.0

100.0

60


Number of living children
0 2.2 4.6 8.0 11.1 7.2 66.8 0.2 100.0 372
1-2 6.2 5.3 9.8 11.7 8.6 58.4 0.0 100.0 784
3-4 7.3 5.1 8.9 6.7 6.3 65.7 0.0 100.0 727
5+ 4.8 3.3 7.4 5.8 5.9 72.8 0.0 100.0 330

Residence
Urban 14.8 14.3 33.0 12.8 7.4 17.7 0.0 100.0 223
Rural 4.7 3.8 6.2 8.6 7.2 69.6 0.0 100.0 1,989

Ecological zone
Mountain 4.2 2.0 6.6 10.5 3.1 73.2 0.4 100.0 147
Hill 6.7 5.6 7.6 10.5 5.1 64.4 0.0 100.0 877
Terai 5.1 4.6 10.0 7.8 9.2 63.2 0.0 100.0 1,187

Development region
Eastern 6.7 4.6 9.7 9.1 9.9 59.9 0.0 100.0 572
Central 5.1 5.4 11.6 11.3 4.9 61.7 0.0 100.0 733
Western 5.6 5.8 8.0 8.5 10.1 62.0 0.0 100.0 428
Mid-western 6.2 1.9 4.8 4.9 5.3 76.8 0.2 100.0 287
Far-western 4.3 5.5 3.7 7.6 4.4 74.4 0.0 100.0 192

Sub-region
Eastern Mountain 4.8 6.0 15.5 6.0 6.0 61.9 0.0 100.0 32
Central Mountain 5.3 0.9 5.3 17.5 3.5 67.5 0.0 100.0 58
Western Mountain 2.9 1.0 2.9 5.9 1.0 85.3 1.0 100.0 57
Eastern Hill 5.3 2.1 3.4 7.6 2.8 78.9 0.0 100.0 160
Central Hill 9.0 10.0 13.6 11.5 2.8 53.1 0.0 100.0 274
Western Hill 8.3 6.9 7.7 13.5 10.8 52.7 0.0 100.0 229
Mid-western Hill 3.5 0.0 3.5 7.5 4.7 80.9 0.0 100.0 137
Far-western Hill 2.9 3.1 2.3 9.9 2.6 79.1 0.0 100.0 78
Eastern Terai 7.5 5.6 11.9 10.0 13.2 51.8 0.0 100.0 380
Central Terai 2.4 2.9 11.2 10.3 6.5 66.7 0.0 100.0 401
Western Terai 2.5 4.5 8.3 2.8 9.3 72.6 0.0 100.0 199
Mid-western Terai 9.5 4.3 6.8 2.7 6.6 70.1 0.0 100.0 124
Far-western Terai 6.6 9.3 4.9 4.9 7.8 66.4 0.0 100.0 82

Education
No education 0.5 3.8 4.4 8.7 8.0 74.6 0.0 100.0 834
Primary 0.8 4.1 7.8 11.7 9.7 65.9 0.0 100.0 663
Some secondary 2.7 8.2 13.4 7.4 5.1 63.1 0.1 100.0 438
SLC and above 37.7 4.5 17.7 6.4 2.0 31.7 0.0 100.0 276

Total 5.7 4.8 8.9 9.1 7.2 64.4 0.0 100.0 2,211
SLC = School Leaving Certificate

Respondents Characteristics and Status * 39





It is clear that education influences the type of occupation. As one becomes more educated,
employment opportunities in the nonagricultural sector increase. Among employed women who have
passed their SLC, 35 percent are involved in professional or clerical occupations, and 12 percent are
engaged in sales and services. Similarly, among men who have passed at least their SLC, 42 percent
are involved in professional or clerical occupations and 18 percent are engaged in sales and services.

3.7 TYPE OF EMPLOYMENT

Although employment is assumed to go hand in hand with payment, not all women and men
who work get paid. Tables 3.7.1 and 3.7.2 show the type of employment for women and men.
Among employed women, 71 percent are not paid (Figure 3.2). This is more common among women
who work in the agricultural sector (77 percent). Only 15 percent of employed women receive cash
earnings (including women who are paid in cash and in-kind). Among employed men, 43 percent
are not paid; this is mostly true in the agricultural sector (64 percent). Forty-two percent of men
receive cash for their work.


Table 3.7.1 Type of employment: women
Percent distribution of women employed in the 12 months preceding the
survey by type of earnings, type of employer, and continuity of employment,
according to type of employment (agricultural or nonagricultural), Nepal 2001


Employment
characteristic
Agricultural
work
Nonagricultural
work Total


Type of earnings

Cash only 2.3 80.4 9.5
Cash and in-kind 5.0 4.5 5.0
In-kind only 15.7 1.8 14.4
Not paid 77.0 13.3 71.1

Total 100.0 100.0 100.0

Type of employer
Employed by family member 53.5 15.8 50.1
Employed by nonfamily member 15.1 37.5 17.2
Self-employed 31.4 46.7 32.8

Total 100.0 100.0 100.0

Continuity of employment
All year 77.0 84.9 77.7
Seasonal 20.9 6.2 19.6
Occasional 2.0 8.9 2.7

Total 100.0 100.0 100.0
Number of women 6,658 674 7,336
Note: Total includes 3 women with missing information on type of employment
who are not shown separately.


40 * Respondents Characteristics and Status




There has been some change in the type of employment women are involved in over the last
five years. A comparison of data collected in the 1996 NFHS and 2001 NDHS shows that more
women are self-employed now than five years ago (33 percent in 2001 compared with only 7 percent
in 1996). Similarly, the proportion of women working for a nonfamily member has increased to
17 percent compared with only 9 percent in 1996. The proportion of women working for a family
member has dropped from 84 percent in 1996 to 50 percent in 2001. This probably indicates that
women have more options to go beyond family work in more recent years.

More than three-quarters of employed women work all year, while 20 percent work
seasonally. As expected, agricultural work is more likely to be seasonal than nonagricultural work.


Table 3.7.2 Type of employment: men
Percent distribution of men employed in the 12 months preceding the survey by
type of earnings, according to type of employment (agricultural or nonagricultural),
Nepal 2001


Type of earnings
Agricultural
work
Nonagricultural
work Total

Cash only 4.5 85.4 33.3
Cash and in-kind 8.1 9.8 8.7
In-kind only 23.1 1.1 15.2
Not paid 64.3 3.7 42.7

Total 100.0 100.0 100.0
Number of men 1,423 788 2,211
Note: Total includes 1 man with missing information on type of employment who
is not shown separately.


Figure 3.2 Type of Earnings of Employed Women Age 15-49
Nepal 2001
Not paid
71%
Cash only
10%
Cash and
in-kind
5% In-kind only
14%

Respondents Characteristics and Status * 41



3.8 DECISION ON USE OF EARNINGS

Access to income alone does not say much about the autonomy of women. They should be
able to have control over their income. Employed women who earn cash for their work were asked
about who primarily makes decisions on the use of their earnings. Table 3.8 shows that 43 percent of
women who earn cash are solely responsible for decisions on the use of their earnings, while
36 percent of women report that they along with their husband or someone else jointly decide how
the money should be spent. One in five women stated that they have no say in how their earnings are
spent. The majority of women in this category are young women age 15-19. Being the sole
decisionmaker rises with age. Married women are equally likely to decide on their own or jointly
with their husband or someone else as to how their earnings are spent. On the other hand, women
who are not currently married are the most likely to make their own decisions about spending their
earnings.

Urban women have more control over their income than rural women. For example,
58 percent of urban women make their own decisions, compared with only 39 percent of rural
women. Women living in the hill ecological zone and those residing in the Central region have more
autonomy over their earnings than women residing in the other regions.

There are only slight differences in decisionmaking by educational level of women.

Information on the contribution of the respondents income to the household expenditure was
also gathered in the 2001 NDHS. It is expected that employment and earnings are more likely to
empower women if their earnings are important for meeting the needs of their household. However,
the income of women is often so small that it can barely meet household needs. Table 3.9 shows that
the earnings of very young women (age 15-19) are less likely to contribute to a major share of
household expenditures than those of older women (20-39 and 45-49). Not surprisingly, women who
are divorced, separated, or widowed tend to contribute a major portion of household expenditure. As
womens level of education increases, their contribution to the household expenditure also increases.
In general, mens contribution to household expenditure is higher than that of women presumably
because men are more likely to be employed for cash and usually earn more than women.

42 * Respondents Characteristics and Status


Table 3.8 Decision on use of earnings
Percent distribution of women who received cash earnings for work in the 12
months preceding the survey by person who decides how earnings are to be used,
according to background characteristics, Nepal 2001

Person who decides how
earnings are used

Background
characteristic Self only Jointly
1

Someone
else only
2
Total
Number
of
women
Age

15-19 25.4 18.3 56.3 100.0 57
20-24 36.7 35.4 27.8 100.0 173
25-29 40.7 35.8 23.5 100.0 213
30-34 40.6 40.7 18.8 100.0 221
35-39 47.8 36.6 15.7 100.0 139
40-44 54.6 31.5 13.9 100.0 160
45-49 50.6 38.3 11.1 100.0 98

Marital status
Married 38.8 38.4 22.8 100.0 968
Divorced/separated/widowed 88.2 5.6 6.2 100.0 93

Number of living children
0 39.2 28.4 32.4 100.0 104
1-2 42.9 32.5 24.6 100.0 414
3-4 45.6 39.6 14.9 100.0 382
5+ 40.4 38.3 21.3 100.0 161

Residence
Urban 57.8 29.1 13.1 100.0 251
Rural 38.6 37.5 23.9 100.0 810

Ecological zone
Mountain 30.0 54.9 15.1 100.0 33
Hill 46.0 31.3 22.7 100.0 452
Terai 41.6 37.7 20.7 100.0 577

Development region
Eastern 44.0 38.1 17.9 100.0 367
Central 53.0 28.7 18.4 100.0 303
Western 40.0 33.1 26.9 100.0 246
Mid-western 22.3 47.2 30.5 100.0 113
Far-western 37.6 47.4 15.1 100.0 32

Education
No education 41.7 34.6 23.8 100.0 664
Primary 43.3 34.5 22.2 100.0 162
Some secondary 46.8 37.8 15.4 100.0 137
SLC and above 47.5 40.4 12.1 100.0 98

Total 43.1 35.5 21.4 100.0 1,061
SLC = School Leaving Certificate

1
With husband or someone else
2
Includes husband

Respondents Characteristics and Status * 43

Table 3.9 Contribution of earnings to household expenditures
Percent distribution of women and men who received cash earnings for work in the 12 months preceding the survey by proportion of household
expenditures met by earnings, according to background characteristics, Nepal 2001

Women Men

Background
characteristic
Almost
none/
none
Less
than half
Half or
more All Missing Total
Number
of
women
Almost
none/
none
Less
than half
Half or
more All Total
Number
of
men

Age

15-19 29.7 30.0 25.4 15.0 0.0 100.0 57 (0.0) (14.5) (36.1) (49.4) 100.0 29
20-24 11.9 33.7 35.1 18.9 0.5 100.0 173 0.7 10.2 45.6 43.5 100.0 126
25-29 8.9 40.1 30.4 20.6 0.0 100.0 213 0.2 11.1 42.1 46.6 100.0 162
30-34 10.9 33.2 38.8 17.1 0.0 100.0 221 0.2 7.3 46.3 46.2 100.0 160
35-39 10.6 25.2 41.3 22.5 0.4 100.0 139 1.5 11.2 44.3 43.0 100.0 143
40-44 3.9 45.7 31.1 19.3 0.0 100.0 160 1.2 10.3 53.6 34.9 100.0 114
45-49 8.1 41.4 29.4 21.1 0.0 100.0 98 1.2 10.5 46.2 42.2 100.0 90
50-54 na na na na na na na 2.1 15.9 54.2 27.9 100.0 62
55-59 na na na na na na na (0.0) (13.6) (43.7) (42.6) 100.0 42

Marital status
Married 10.7 36.8 34.4 18.1 0.1 100.0 968 0.8 10.6 46.8 41.8 100.0 908
Divorced/separated/
widowed
6.7 29.0 30.9 32.9 0.6 100.0 93 * * * * 100.0 22


Number of living children
0 20.9 32.0 27.6 19.5 0.0 100.0 104 0.9 17.9 44.3 36.8 100.0 142
1-2 11.6 33.0 34.8 20.3 0.2 100.0 414 0.4 9.4 39.8 50.5 100.0 376
3-4 7.7 36.0 36.5 19.7 0.1 100.0 382 1.2 9.1 52.0 37.7 100.0 303
5+ 6.4 46.9 30.6 16.1 0.0 100.0 161 1.2 10.2 54.3 34.3 100.0 109

Residence
Urban 11.1 28.1 38.1 22.4 0.3 100.0 251 1.4 9.4 34.7 54.6 100.0 180
Rural 10.1 38.6 32.8 18.5 0.1 100.0 810 0.7 11.0 48.9 39.4 100.0 750

Ecological zone
Mountain 4.4 22.1 28.3 45.3 0.0 100.0 33 2.8 9.5 51.9 35.8 100.0 41
Hill 8.6 33.4 38.5 19.3 0.2 100.0 452 1.3 13.2 46.5 39.0 100.0 340
Terai 12.0 39.0 30.9 18.0 0.1 100.0 577 0.3 9.3 45.5 44.8 100.0 549

Development region
Eastern 11.4 37.7 32.5 18.4 0.0 100.0 367 0.8 14.0 52.0 33.2 100.0 291
Central 12.8 31.0 36.0 20.0 0.3 100.0 303 0.5 8.7 35.7 55.1 100.0 344
Western 8.1 46.0 32.7 13.3 0.0 100.0 246 1.8 11.1 54.7 32.4 100.0 181
Mid-western 4.9 20.7 39.4 34.9 0.0 100.0 113 0.0 8.5 50.4 41.0 100.0 66
Far-western 12.0 44.3 25.2 16.8 1.6 100.0 32 0.0 6.4 47.8 45.8 100.0 48

Education
No education 9.9 42.7 32.1 15.3 0.1 100.0 664 0.9 9.9 51.8 37.4 100.0 303
Primary 7.9 29.0 38.1 24.9 0.0 100.0 162 1.0 9.5 50.5 39.0 100.0 260
Some secondary 14.3 22.1 35.8 27.2 0.6 100.0 137 0.8 13.3 41.4 44.5 100.0 169
SLC and above 11.7 22.6 38.4 27.3 0.0 100.0 98 0.5 11.3 35.9 52.3 100.0 198

Total 10.3 36.1 34.1 19.4 0.1 100.0 1,061 0.8 10.7 46.2 42.3 100.0 930
Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has
been suppressed.
na = Not applicable
SLC = School Leaving Certificate


44 * Respondents Characteristics and Status






Table 3.10 shows the percent distribution of currently married women who receive cash
earnings by the person who decides how their earnings are used, according to their contribution to
household expenditures. The table shows that a womans autonomy over her earnings increases as
their contribution to the household expenditures declines. For example, more than one in two
women who contribute almost nothing toward household expenditure have sole autonomy over their
earnings. On the other hand, women whose earnings constitute a larger proportion of household
expenditures are also more likely to have their husband involved in the decisionmaking. For
example, 46 percent of women whose earnings constitute all of the household expenditures make
joint decisions with their husband.

Table 3.10 Women's control over earnings
Percent distribution of currently married women who received cash earnings for work in the
past 12 months by person who decides how earnings are used, according to proportion of
household expenditures met by earnings, Nepal 2001



Person who decides how earnings are used



Contribution to
household
expenditures Self only
Jointly
with
husband
Jointly
with
someone
else
Husband
only
Someone
else only Total
Number
of
women

Almost none/ none 54.1 17.0 2.1 15.1 11.8 100.0 103
Less than half 43.3 32.1 2.6 14.4 7.6 100.0 356
Half or more 33.9 42.4 1.4 16.8 5.5 100.0 333
All 30.1 46.0 1.2 17.6 5.1 100.0 175

Total 38.8 36.5 1.9 15.9 6.9 100.0 968

Note: Total includes 1 woman with missing information on contribution to household
expenditures who is not shown separately




3.9 WOMENS EMPOWERMENT AND STATUS

Womens status has a direct effect on the health and nutritional status of women and children.
Therefore, it is important to review information on the status of women in Nepal. Besides other
indicators like educational attainment, type of employment, and control over income, the 2001
NDHS also reviewed indicators like decisionmaking within the household, womens attitudes toward
wife beating, and their attitudes about the ability of married women to refuse sex with their husband.
Women who have a greater say in household decisionmaking, women who do not believe that a man
is justified in beating his wife for any reason, and women who feel women should be able to refuse
sex with their husband for any reason are relatively more empowered.
Respondents Characteristics and Status * 45


HOUSEHOLD DECISIONMAKING

To assess womens weight in household decisionmaking, respondents were asked who in
their family usually has the final say on five different types of decisions, namely, their own health
care, large household purchases, daily household purchases, visits to family or relatives, and what
food to cook each day. The percent distribution of women according to the person who usually has
the final say in different decisions is shown in Table 3.11. The data are presented separately for
women who are currently married and women who are divorced, separated, or widowed.

With the exception of what food to cook, husbands in Nepal have a greater say in
decisionmaking than wives. For example, one in two married women states that their husband alone
has final say in making decisions about the wifes health care. In general women have a much greater
say in what food to cook each day since cooking is often perceived as womens work, with little
male involvement. The data also show that two in five married women state that their husband makes
the sole decision on the purchase of large household items, while one in three states that they need
their husbands permission to visit family or relatives and to make daily household purchases. The
table also shows that currently married women are much less likely to have a final say in any of the
five types of decisions than women who are divorced, separated, or widowed. Even so, about one in
four previously married women has someone else making decisions for them. Similar questions were
posed to men in the 2001 NDHS. Mens responses closely reflected the situation indicated by
womens responses (data not shown).



Table 3.11 Womens participation in decisionmaking
Percent distribution of women by person who has the final say in making specific decisions, according to current marital status and type of decision, Nepal 2001
Currently married Divorced/Separated/Widowed

Decision
Self only
Jointly
with
husband
Jointly
with
someone
else
Husband
only
Someone
else only
Decision
not made/
not
applicable Total
Number
of
women Self only
Jointly
with
someone
else
Someone
else only
Decision
not made/
not
applicable Total
Number
of
women

Own health care 13.4 12.1 1.8 51.0 21.1 0.5 100.0 8,342 65.6 5.9 27.7 0.8 100.0 384
Large household
purchases 13.0 17.3 1.7 41.1 26.6 0.3 100.0 8,342 65.4 5.8 28.1 0.7 100.0 384

Daily household
purchases 26.8 14.6 1.9 30.3 26.3 0.1 100.0 8,342 70.8 2.4 26.8 0.0 100.0 384

Visits to family or
relatives 15.0 21.2 2.6 33.7 27.4 0.1 100.0 8,342 69.7 5.9 24.2 0.2 100.0 384

What food to cook
each day

71.0

1.5

8.5

1.3

17.6

0.0

100.0

8,342

72.1

9.4

18.5

0.0

100.0

384



Table 3.12 shows how womens participation in household decisions varies by background
characteristics. Note that women are considered as participating in a decision if they make decisions
alone or jointly with their husband or someone else. Only one in five women has a say in all five
decisions, while 15 percent have no say in any of the five decisions (Figure 3.3).
46 * Respondents Characteristics and Status

Table 3.12 Women's participation in decisionmaking by background characteristics
Percentage of women who say that they alone or jointly have the final say in specific decisions, by background characteristics, Nepal
2001


Alone or jointly have final say in:


Background
characteristic
Own
health
care
Making
large
purchases
Making
daily
purchases
Visits to
family or
relatives
What food
to cook
daily
All
specified
decisions
None of
the
specified
decisions


Number
of
women
Age
15-19 7.4 7.9 10.6 10.4 50.7 2.8 46.1 941
20-24 20.3 20.0 28.1 26.0 70.1 11.3 25.7 1,658
25-29 30.2 32.8 45.5 40.0 83.8 19.4 12.7 1,666
30-34 31.9 40.1 54.1 46.4 88.7 22.4 8.5 1,427
35-39 38.0 46.3 59.4 53.3 94.1 28.6 3.5 1,168
40-44 38.9 47.7 60.1 55.3 92.0 29.4 4.3 1,030
45-49 41.1 46.9 58.4 56.8 87.2 27.8 5.8 837

Marital status
Married 27.3 32.1 43.3 38.8 81.1 17.8 15.4 8,342
Divorced/separated/widowed 71.5 71.2 73.2 75.6 81.5 61.8 11.1 384

Number of living children
0 11.8 13.7 17.1 16.0 55.0 5.9 40.6 1,051
1-2 27.8 29.8 39.0 35.5 75.8 17.9 20.1 3,101
3-4 34.9 42.4 56.4 50.1 89.8 24.9 6.7 3,016
5+ 33.1 38.6 52.0 47.9 92.5 23.0 4.7 1,557

Residence
Urban 39.8 46.2 60.7 52.0 86.1 26.1 8.2 841
Rural 28.2 32.5 42.9 39.2 80.6 19.1 15.9 7,885

Ecological zone
Mountain 22.5 22.2 30.8 31.6 83.0 14.2 15.1 602
Hill 33.2 35.5 47.0 44.4 81.2 22.4 14.7 3,615
Terai 27.1 33.9 44.7 38.4 80.8 18.4 15.6 4,509

Development region
Eastern 27.6 38.1 50.4 39.3 84.8 19.3 11.4 2,098
Central 30.3 32.2 41.8 41.6 82.0 20.1 14.7 2,804
Western 33.3 38.1 46.8 42.0 75.7 21.4 18.9 1,771
Mid-western 29.3 29.8 45.4 43.9 81.6 21.2 16.2 1,197
Far-western 21.7 25.2 34.3 31.2 79.7 14.5 17.1 855

Subregion
Eastern Mountain 31.5 39.4 50.9 42.1 88.2 22.7 10.3 126
Central Mountain 28.4 19.7 26.6 34.4 82.8 13.4 14.7 209
Western Mountain 13.6 16.0 24.6 24.4 80.8 10.8 17.7 267
Eastern Hill 26.0 35.6 44.2 35.2 84.2 18.4 12.4 580
Central Hill 38.8 35.3 44.8 46.1 82.5 22.9 12.0 945
Western Hill 37.0 42.4 53.2 46.9 76.1 25.0 18.1 1,075
Mid-western Hill 30.7 30.0 48.2 51.5 86.3 23.8 12.7 648
Far-western Hill 23.1 25.4 36.3 34.6 78.9 17.6 18.5 368
Eastern Terai 28.0 38.9 53.0 40.7 84.7 19.4 11.1 1,393
Central Terai 25.7 32.0 42.1 40.0 81.5 19.3 16.3 1,651
Western Terai 27.4 31.3 36.8 34.3 75.1 15.9 20.2 696
Mid-western Terai 30.8 33.0 44.1 35.2 74.4 20.1 21.3 438
Far-western Terai 24.3 29.2 39.9 33.7 80.6 12.6 14.6 331

Education
No education 29.0 33.4 44.3 40.9 83.3 19.8 13.3 6,279
Primary 28.8 32.5 43.3 38.8 75.1 19.7 20.7 1,294
Some secondary 28.1 33.8 45.3 37.0 73.6 17.9 22.0 814
SLC and above 39.6 46.4 54.9 46.0 81.0 23.7 12.5 339

Employment
Not employed 23.1 29.6 38.6 31.9 77.1 15.2 20.3 1,496
Employed for cash 45.5 54.2 67.7 56.4 88.8 32.7 5.7 1,009
Employed not for cash 28.2 31.5 42.4 39.9 80.8 18.8 15.5 6,220

Total 29.3 33.8 44.7 40.4 81.1 19.8 15.2 8,726
Note: Total includes 2 women with missing information on employment who are not shown separately.
SLC = School Leaving Certificate


Respondents Characteristics and Status * 47
15
31
12 12
10
20
0 1 2 3 4 5
Number of decisions
0
10
20
30
40
Percent
Figure 3.3 Distribution of Women by Number of Decisions
in Which They Participate
Nepal 2001


Womens participation in household decisionmaking increases with age. As observed earlier,
divorced, separated, and widowed women have a greater say in decisionmaking than currently
married women. A womans involvement in decisionmaking also increases with the number of
children she has, presumably because in Nepal having children confers a higher status on women.
Urban women have a greater say in household decisionmaking than rural women. Twenty-
six percent of women in urban areas participate in all of the specified decisions, compared with
19 percent of rural women. Women residing in the hill ecological zone also seem to have more say
in household decisionmaking than women residing in the terai or mountain zones. Women residing
in the Far-western development region are less likely than women residing in other regions to have
decisionmaking input.

Womens education has a slight relationship to household decisionmaking. Womens
employment status is related to level of participation in household decisions. Women who are
employed and earn cash have more say in household decisionmaking than women who do not work
and women who work but do not earn cash income.
ATTITUDE TOWARD WIFE BEATING

The 2001 NDHS gathered information on womens and mens attitudes toward wife beating,
another proxy for womens status. Women and men were asked whether a husband would be
justified in beating his wife in each of five scenarios: if she burns food, if she argues with him, if she
goes out without telling him, if she neglects the children, and if she refuses sex with him. The first
five columns in Tables 3.13.1 and 3.13.2 show how the acceptance of wife beating varies for each
reason. The sixth column gives the percentages of women and men who feel a husband is justified in
beating his wife for at least one of the given reasons. Note that empowerment decreases as the
value of this indicator increases. This means, the more reasons agreed with, the lower the level of
womens empowerment according to this indicator.
48 * Respondents Characteristics and Status


Table 3.13.1 Women's attitude toward wife beating


Percentage of women who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics,
Nepal 2001

Husband is justified in hitting or beating his wife if she:


Background
characteristic
Burns the
food
Argues with
him
Goes out
without
telling him
Neglects
the
children
Refuses to
have sex
with him
Percentage
who agree
with at
least one
specified
reason
Number
of
women

Age

15-19 6.3 11.2 12.5 28.0 3.2 32.1 941
20-24 5.6 9.1 13.6 26.2 2.7 29.8 1,658
25-29 4.5 8.7 12.4 27.6 2.7 31.0 1,666
30-34 3.6 7.4 10.7 25.0 3.3 28.5 1,427
35-39 5.1 7.9 11.4 23.2 2.9 26.6 1,168
40-44 4.6 8.0 12.3 23.2 3.8 26.2 1,030
45-49 6.0 9.6 12.7 20.5 3.4 25.2 837

Marital status
Married 5.0 8.6 12.1 25.1 3.0 28.7 8,342
Divorced/separated/widowed 6.3 10.5 14.7 25.8 4.3 30.0 384

Number of living children
0 6.9 11.1 13.4 26.9 3.5 31.0 1,051
1-2 4.5 8.2 12.1 26.3 2.6 29.7 3,101
3-4 4.8 8.5 12.4 25.0 3.3 28.6 3,016
5+ 5.2 8.7 11.4 22.1 3.3 25.8 1,557

Residence
Urban 3.9 8.0 13.2 29.0 2.7 33.2 841
Rural 5.1 8.8 12.1 24.8 3.1 28.3 7,885

Ecological zone
Mountain 2.9 5.2 13.4 26.8 1.9 29.3 602
Hill 1.9 4.6 8.8 22.1 1.6 25.0 3,615
Terai 7.8 12.5 14.8 27.5 4.4 31.7 4,509

Development region
Eastern 4.1 7.2 12.7 25.9 2.0 29.8 2,098
Central 9.3 13.3 13.3 22.8 4.7 26.5 2,804
Western 3.8 5.9 8.4 20.3 2.9 23.6 1,771
Mid-western 1.2 5.8 11.8 36.5 3.0 38.7 1,197
Far-western 1.2 7.5 15.8 25.4 0.9 30.4 855

Subregion
Eastern Mountain 2.1 5.2 12.1 24.8 0.9 27.3 126
Central Mountain 2.5 3.5 7.8 17.5 1.3 20.3 209
Western Mountain 3.5 6.5 18.4 35.0 2.8 37.4 267
Eastern Hill 1.1 2.3 6.3 15.4 0.6 18.1 580
Central Hill 3.7 5.3 10.6 22.2 2.6 25.0 945
Western Hill 1.9 4.3 5.1 16.5 1.4 19.1 1,075
Mid-western Hill 0.6 5.3 11.0 35.7 2.2 38.0 648
Far-western Hill 0.7 6.2 15.0 24.3 0.3 30.0 368
Eastern Terai 5.5 9.5 15.5 30.3 2.7 34.9 1,393
Central Terai 13.3 19.1 15.6 23.8 6.4 28.3 1,651
Western Terai 6.7 8.4 13.5 26.1 5.2 30.4 696
Mid-western Terai 0.6 5.5 11.9 35.1 3.4 37.4 438
Far-western Terai 1.7 10.6 14.8 26.0 1.8 30.9 331

Education
No education 5.9 9.4 12.9 24.8 3.8 28.4 6,279
Primary 4.0 8.6 12.5 26.2 2.0 30.6 1,294
Some secondary 1.6 5.8 8.6 26.6 0.9 29.6 814
SLC and above 0.8 3.2 7.7 24.5 0.0 26.2 339

Employment
Not employed 7.6 12.9 15.0 28.2 3.9 32.2 1,496

Employed for cash 4.7 8.4 13.7 27.6 3.0 31.6 1,009

Employed not for cash 4.4 7.8 11.4 24.0 2.9 27.5 6,220



Number of decisions in which
woman has final say
1

0 5.8 10.2 12.9 25.9 3.2 29.8 1,327
1-2 4.3 8.2 12.2 24.7 3.1 28.4 3,761
3-4 6.9 10.4 13.2 28.1 3.5 31.9 1,914
5 3.8 6.9 10.6 22.4 2.6 25.4 1,725

Total 5.0 8.7 12.2 25.2 3.1 28.8 8,726
Note: Total includes 2 women with missing information on employment who are not shown separately.
SLC = School Leaving Certificate

1
Either by herself or jointly with others


Respondents Characteristics and Status * 49

Table 3.13.2 Men's attitude toward wife beating


Percentage of men who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics,
Nepal 2001


Husband is justified in hitting or beating his wife if she:


Background
characteristic
Burns the
food
Argues with
him
Goes out
without
telling him
Neglects
the
children
Refuses to
have sex
with him
Percentage
who agree
with at
least one
specified
reason
Number
of
men

Age



15-19 3.4 21.8 21.7 39.2 7.2 46.3 70


20-24 3.4 19.8 19.4 33.3 11.2 40.7 295


25-29 3.3 17.0 17.0 29.6 9.7 37.9 340


30-34 3.1 18.7 15.5 27.3 6.1 34.5 344


35-39 5.2 14.4 15.3 24.8 8.8 30.1 322


40-44 3.4 15.0 15.8 26.0 8.6 31.2 261


45-49 3.1 17.5 18.2 22.8 9.2 30.3 243


50-54 3.1 17.2 13.7 25.8 7.5 31.6 216


55-59 1.6 18.2 12.3 23.1 5.7 29.6 171





Marital status


Married 3.4 17.3 16.3 27.3 8.5 34.1 2,198


Divorced/separated/widowed 3.1 18.1 16.0 27.9 6.1 33.7 63





Number of living children


0 3.1 17.6 16.7 28.9 9.3 36.6 392


1-2 4.2 17.6 15.8 27.3 7.5 34.0 793


3-4 3.5 17.5 17.5 28.0 9.2 34.6 740


5+ 1.9 16.1 14.8 24.4 8.1 30.2 336





Residence


Urban 0.6 11.1 10.2 20.0 5.1 25.5 227


Rural 3.7 18.0 17.0 28.2 8.8 35.0 2,034





Ecological zone


Mountain 5.0 22.6 20.5 31.5 14.5 38.7 151


Hill 2.6 15.5 13.9 27.1 6.1 33.6 896


Terai 3.8 18.0 17.6 27.0 9.5 33.9 1,214





Development region


Eastern 2.3 22.1 18.8 26.1 9.0 35.0 583


Central 2.3 11.2 9.8 17.3 4.1 21.1 750


Western 4.7 14.7 17.0 29.6 8.3 35.7 436


Mid-western 5.5 23.0 22.6 40.4 12.1 49.4 295


Far-western 4.9 24.2 23.2 44.7 18.1 54.2 197





Subregion


Eastern Mountain 1.2 14.0 16.3 24.4 7.0 30.2 33


Central Mountain 1.7 4.3 6.0 6.8 2.6 9.4 59


Western Mountain 10.6 46.2 37.5 60.6 30.8 73.1 59


Eastern Hill 2.1 24.6 17.1 32.8 8.9 42.4 161


Central Hill 0.8 7.3 7.0 17.2 1.8 20.4 278


Western Hill 2.8 13.9 12.2 22.7 7.9 28.9 235


Mid-western Hill 5.6 26.2 28.0 38.1 7.8 49.8 143


Far-western Hill 3.8 11.6 11.4 43.3 6.8 46.3 80


Eastern Terai 2.6 21.7 19.7 23.5 9.3 32.4 389


Central Terai 3.3 14.8 12.2 18.9 5.9 23.3 413


Western Terai 6.9 15.6 22.5 37.6 8.9 43.5 201


Mid-western Terai 5.1 16.6 15.4 39.8 12.8 45.9 126


Far-western Terai 2.4 24.6 25.9 38.5 24.4 51.5 85





Education


No education 4.8 22.8 20.8 32.6 10.5 40.1 852


Primary 3.7 19.9 18.7 30.1 9.6 37.9 670


Some secondary 2.2 11.9 12.1 23.5 6.5 30.6 452


SLC and above 0.2 3.8 4.2 11.5 2.8 12.8 287





Employment


Not employed 0.0 14.1 11.8 17.6 12.4 24.0 77


Employed for cash 3.2 15.7 14.5 24.5 6.8 30.6 915


Employed not for cash 3.7 18.8 17.9 30.0 9.4 37.2 1,268





Number of decisions in which
man has final say
1



0 1.4 19.5 14.9 30.1 6.9 35.1 101


1-2 3.7 15.6 13.9 26.4 9.1 33.2 401


3-4 3.0 17.4 16.1 26.5 8.5 33.4 1,588


5 8.1 19.8 24.9 35.5 7.8 41.5 171





Total 3.4 17.3 16.3 27.4 8.5 34.1 2,261

SLC = School Leaving Certificate

1
Either by himself or jointly with others
50 * Respondents Characteristics and Status






Twenty-nine percent of women age 15-49 in Nepal agree that a husband is justified in beating
his wife for at least one reason (Table 3.13.1). One in four women agrees that wife beating is
justified if a woman neglects her children, while 12 percent agree that a husband is justified in
beating his wife if she goes out without telling him. Nevertheless, less than 10 percent of women feel
that a husband is justified in beating his wife if she refuses to have sex with him, burns the food, or
argues with him. Age has some influence on a wifes empowerment as measured by this indicator;
the older a woman, the less likely she is to believe that a husband is justified in beating his wife for a
specified reason. Surprisingly, rural women are slightly less likely to agree that wife beating is
justified for any reason at all than urban women, and education and employment play a small role in
womens attitudes toward wife beating. Women residing in the hill zone, in the Western region, and
in the Eastern hill subregion are somewhat less likely than other women to agree that wife beating is
justified for any reason.

Participation in decisionmaking is related to womens attitudes toward wife beating. Women
who have a greater say in household decisionmaking are less likely to agree that wife beating is
justified for any reason.

To understand the environment in which women live, men were also asked their opinions
about wife beating (Table 3.13.2). Men are more likely than women to feel that husbands are
justified in beating their wives for at least one reason (34 percent and 29 percent, respectively).
While the pattern for specific reasons is somewhat similar, men are twice as likely as women to say
that a man is justified in beating his wife if she argues with him and three times more likely if she
refuses to have sex with him. The pattern by age, marital status, number of living children,
ecological region, and say in decisionmaking is similar to that seen for women. However, rural men
are more likely than urban men to agree that wife beating is justified for at least one reason. More
than one in two men living in the Far-western region agree with wife beating for at least one reason.
Men living in the Central mountain region are much less likely than men living in any other
subregion to condone wife beating. Mens education is much more strongly related to attitude
toward wife beating than womens education.
ATTITUDE TOWARD REFUSING SEX WITH HUSBAND

Another proxy indicator to assess the status of women used in the 2001 NDHS was the
respondents attitude toward womens right and control over their own sexuality as measured by
their opinion on a womans right to refuse sex with her husband. The opinion of both men and
women was sought to derive a holistic picture. To measure the respondents attitude on a womans
right to refuse sex with her husband, the 2001 NDHS asked respondents whether a wife is justified in
refusing to have sex with her husband under four circumstances: she knows that her husband has a
sexually transmitted disease, she knows that her husband has sex with other women, she has recently
given birth, and she is not in the mood. These four circumstances were chosen because they combine
womens rights and womens health issues. Table 3.14.1 shows the percentage of women who say
that women are justified in refusing sex with their husband for specific reasons by background
characteristics. Note that unlike the previous indicator of empowerment, this indicator is positively
related to empowerment: the more reasons women agree with, the higher their empowerment in
terms of their belief in womens sexual rights.
Respondents Characteristics and Status * 51


Table 3.14.1 Women's attitude toward refusing sex with husband


Percentage of women who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background characteristics, Nepal 2001


Wife is justified in refusing sex with husband if she:


Background
characteristic
Knows husband
has a sexually
transmitted
disease
Knows husband
has sex with
other women
Has recently
given
birth
Is tired or
not in
the mood

Percentage
who agree
with all of
the specified
reasons

Percentage
who agree
with none of
the specified
reasons
Number
of
women

Age



15-19 95.8 94.1 97.2 96.4 90.6 1.1 941


20-24 95.8 94.0 97.7 97.2 90.9 1.0 1,658


25-29 95.3 93.5 97.3 96.4 89.1 1.0 1,666


30-34 95.9 93.8 97.4 96.7 90.3 1.2 1,427


35-39 94.3 94.0 96.8 96.1 89.7 1.5 1,168


40-44 94.8 94.2 97.6 96.3 89.4 1.1 1,030


45-49 94.2 93.5 97.3 96.8 90.0 1.3 837





Marital status


Married 95.3 93.9 97.4 96.7 90.1 1.1 8,342


Divorced/separated/widowed 94.8 93.8 95.8 94.3 88.4 2.2 384





Number of living children


0 95.6 93.6 96.9 96.2 89.9 1.3 1,051


1-2 95.9 93.6 97.8 96.8 90.7 1.0 3,101


3-4 95.3 94.3 97.3 97.1 89.9 0.9 3,016


5+ 93.8 93.7 96.8 95.4 89.0 1.9 1,557





Residence


Urban 95.1 92.1 97.2 94.6 88.5 1.6 841


Rural 95.3 94.0 97.4 96.8 90.2 1.1 7,885





Ecological zone


Mountain 96.6 94.3 98.9 98.4 92.8 1.0 602


Hill 96.3 95.0 98.2 97.5 92.2 1.0 3,615


Terai 94.2 92.9 96.5 95.6 87.9 1.3 4,509





Development region


Eastern 97.0 93.9 96.6 96.3 91.3 1.6 2,098


Central 95.4 94.8 96.5 96.0 91.0 1.5 2,804


Western 97.6 95.6 98.5 96.7 92.1 0.4 1,771


Mid-western 87.4 89.2 99.1 97.7 80.8 0.6 1,197


Far-western 96.8 93.7 97.4 97.3 91.8 1.3 855





Subregion


Eastern Mountain 99.4 98.5 100.0 99.7 97.6 0.0 126


Central Mountain 96.5 96.5 97.7 97.7 95.4 2.3 209


Western Mountain 95.5 90.7 99.4 98.3 88.6 0.4 267


Eastern Hill 98.7 94.9 98.7 98.5 93.5 0.8 580


Central Hill 94.7 93.6 97.0 95.4 90.1 1.9 945


Western Hill 99.0 98.2 98.8 98.1 96.4 0.6 1,075


Mid-western Hill 92.0 92.5 99.2 98.2 87.1 0.5 648


Far-western Hill 96.8 93.5 97.4 97.9 91.8 1.0 368


Eastern Terai 96.1 93.1 95.5 95.1 89.9 2.1 1,393


Central Terai 95.6 95.3 96.0 96.0 91.0 1.3 1,651


Western Terai 95.5 91.5 98.0 94.6 85.5 0.0 696


Mid-western Terai 79.4 84.8 98.8 97.2 71.4 0.8 438


Far-western Terai 96.2 93.9 96.4 95.7 91.0 2.0 331





Education


No education 94.4 93.8 96.9 96.3 89.3 1.3 6,279


Primary 96.9 93.9 98.2 97.3 91.4 1.0 1,294


Some secondary 98.3 94.6 98.9 97.8 92.9 0.6 814


SLC and above 97.4 93.7 98.4 95.4 90.8 1.3 339





Employment


Not employed 94.6 92.2 96.3 95.7 88.5 1.7 1,496


Employed for cash 94.7 93.3 98.0 94.9 88.3 1.1 1,009


Employed not for cash 95.5 94.4 97.5 97.0 90.7 1.1 6,220





Number of decisions in which
woman has final say
1




0 95.1 93.0 97.7 97.4 90.0 1.1 1,327


1-2 94.8 93.2 97.6 96.4 89.3 1.2 3,761


3-4 95.8 95.5 97.4 96.8 91.1 1.0 1,914


5 95.6 94.2 96.6 96.0 90.2 1.4 1,725




Number of reasons wife
beating is justified



0 96.1 95.0 97.6 97.1 91.9 1.2 6,216


1-2 93.7 90.8 96.8 95.4 85.5 1.2 1,940


3-4 91.8 91.3 96.6 94.4 83.9 1.0 457


5 91.2 95.5 98.9 97.1 85.7 0.0 113





Total 95.3 93.9 97.4 96.6 90.0 1.2 8,726


Note: Total includes 2 women with missing information on employment who are not shown separately.
SLC = School Leaving Certificate

1
Either by herself or jointly with others

52 * Respondents Characteristics and Status

Table 3.14.2 Men's attitude toward refusing sex with husband
Percentage of men who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background characteristics, Nepal 2001
Wife is justified in refusing sex with husband if she:

Background
characteristic
Knows husband
has a sexually
transmitted
disease
Knows husband
has sex with
other women
Has recently
given
birth
Is tired or
not in
the mood

Percentage
who agree
with all of the
specified
reasons

Percentage
who agree
with none of
the specified
reasons
Number
of
men

Age



15-19 92.4 84.2 89.3 90.1 76.0 1.4 70


20-24 94.7 80.4 93.8 90.6 74.0 2.1 295


25-29 92.7 84.0 94.0 94.4 80.3 3.3 340


30-34 90.2 82.7 91.0 88.8 76.7 5.3 344


35-39 92.4 82.5 91.6 88.4 77.0 4.3 322


40-44 92.1 84.6 93.7 93.6 81.4 4.6 261


45-49 89.1 82.9 89.7 88.1 80.0 8.0 243


50-54 87.1 81.7 89.2 89.7 77.5 7.6 216


55-59 82.6 76.9 86.4 87.1 71.9 9.8 171




Marital status


Married 91.2 82.8 91.7 90.4 78.0 5.0 2,198


Divorced/separated/widowed 76.8 66.2 84.9 86.8 59.2 7.3 63




Number of living children


0 88.9 80.5 88.5 88.5 73.6 6.1 392


1-2 91.1 81.8 92.0 90.1 76.7 4.7 793


3-4 91.7 83.5 92.6 90.7 79.4 5.1 740


5+ 90.3 83.0 91.5 91.9 79.6 4.8 336




Residence


Urban 92.1 81.4 91.6 90.5 76.7 3.8 227


Rural 90.6 82.4 91.5 90.3 77.6 5.2 2,034




Ecological zone


Mountain 89.9 85.2 96.3 94.8 82.4 2.3 151


Hill 92.8 78.3 91.6 90.6 74.1 4.8 896


Terai 89.4 84.9 90.9 89.5 79.4 5.6 1,214




Development region


Eastern 95.2 91.3 96.7 93.4 87.1 2.4 583


Central 94.1 87.8 94.1 93.7 83.4 2.7 750


Western 88.3 71.9 86.9 90.2 66.0 5.2 436


Mid-western 76.6 63.2 82.1 76.1 56.7 14.8 295


Far-western 91.9 86.9 90.4 89.5 83.6 6.8 197




Subregion


Eastern Mountain 96.5 93.0 97.7 94.2 88.4 1.2 33


Central Mountain 90.6 88.0 95.7 96.6 86.3 3.4 59


Western Mountain 85.6 77.9 96.2 93.3 75.0 1.9 59


Eastern Hill 96.6 94.1 97.9 93.8 90.0 1.4 161


Central Hill 96.1 82.4 92.7 93.0 76.2 1.0 278


Western Hill 95.7 70.7 93.4 93.2 66.2 1.7 235


Mid-western Hill 83.2 66.4 85.4 84.3 65.2 14.6 143


Far-western Hill 82.5 76.5 80.3 78.7 74.2 16.7 80


Eastern Terai 94.5 90.0 96.2 93.2 85.7 3.0 389


Central Terai 93.2 91.4 94.8 93.7 87.8 3.8 413


Western Terai 79.8 73.2 79.3 86.7 65.8 9.4 201


Mid-western Terai 70.9 62.2 76.3 64.9 49.4 17.2 126


Far-western Terai 97.6 91.8 96.4 95.8 86.4 0.0 85




Education


No education 84.5 78.9 87.9 87.3 74.1 8.6 852


Primary 94.9 85.1 93.8 92.4 80.7 2.5 670


Some secondary 93.1 83.3 92.6 92.3 79.6 4.1 452


SLC and above 96.1 84.5 95.1 91.3 76.9 2.1 287




Employment


Not employed 90.8 81.2 89.4 87.1 71.3 3.5 77


Employed for cash 92.0 81.7 92.6 91.3 76.6 3.7 915


Employed not for cash 89.9 82.9 90.9 89.8 78.5 6.1 1,268




Number of decisions in which
man has final say
1




0 91.1 79.0 85.5 83.2 68.4 5.1 101


1-2 93.0 83.3 91.5 90.3 75.6 2.5 401


3-4 91.6 84.0 92.9 91.4 80.7 5.2 1,588


5 77.9 66.7 81.9 83.8 57.6 9.7 171




Number of reasons wife
beating is justified



0 92.5 84.4 92.6 92.2 80.9 4.7 1,490


1-2 88.4 78.7 88.9 87.2 72.1 6.2 508


3-4 84.7 77.3 90.4 84.5 67.6 4.7 230


5 90.4 80.2 92.1 92.1 78.5 7.9 32





Total 90.8 82.3 91.5 90.3 77.5 5.1 2,261


SLC = School Leaving Certificate

1
Either by himself or jointly with others

Respondents Characteristics and Status * 53
It is encouraging to note that most women (90 percent) in Nepal feel that women are justified
in refusing sex with their husband for all four reasons given, with little variation by specific reason,
background characteristics, or other womens status indicators.

It is important to assess mens perceptions of womens rights over their sexuality because it
has implications for womens reproductive health. In general, men are less likely than women to
agree that a wife is justified in refusing sex with her husband for all reasons, with the biggest
discrepancy for the reason knows husband has sex with other women (Table 3.14.2).
Nevertheless, more than three-fourths of men (compared with nine-tenths of women) agree that a
wife is justified in refusing sex with her husband for all four reasons.

Men age 55-59; divorced, separated, or widowed men; men with no children; men living in
the hill ecological zone, the Mid-western development region, and the Mid-western terai subregion;
men with no education; men not currently employed; men who have a final say in the five household
decisions; and men who believe that wife beating is justified for three to four reasons are less likely
than their counterparts to agree that a wife is justified in refusing sex with her husband for all four
reasons.

3.10 SMOKING AND ALCOHOL CONSUMPTION

Smoking is associated with increased risk of lung and heart diseases and is also closely
related to other behaviors risky to health, such as alcohol and drug use. Table 3.15 presents
information on mens smoking and alcohol consumption status.

Nearly three-fourths of men smoke cigarettes, bidis, or other tobacco, two-thirds have ever
consumed alcohol, and more than one in two both smoke and have consumed alcohol. Smoking and
alcohol consumption is much less common among men in the youngest age group (15-19). Smoking
and alcohol consumption is also less common among divorced, separated, or widowed men and men
living in the terai ecological zone, Western development region, and Central terai subregion than
among their counterparts.


54 * Respondents Characteristics and Status


Table 3.15 Smoking and alcohol consumption
Percentage of men who smoke cigarettes/bidis/tobacco and percentage of men who
have ever consumed alcohol, by background characteristics, Nepal 2001


Background
characteristic
Smokes
cigarettes/
bidis/tobacco
Has
consumed
alcohol
Smokes and
has
consumed
alcohol
Number
of
men


Age
15-19 36.7 47.4 24.6 70
20-24 59.2 64.4 39.9 295
25-29 68.5 73.3 54.7 340
30-34 72.7 69.9 54.5 344
35-39 73.4 67.7 51.3 322
40-44 80.1 71.7 60.2 261
45-49 80.0 71.0 58.3 243
50-54 87.4 61.7 53.6 216
55-59 82.2 60.4 52.1 171

Marital status
Married 72.9 67.6 52.2 2,198
Divorced/separated/widowed 77.5 64.7 45.7 63

Residence
Urban 65.4 75.0 50.7 227
Rural 73.9 66.7 52.2 2,034

Ecological zone
Mountain 76.5 72.7 58.0 151
Hill 69.2 77.0 55.8 896
Terai 75.5 59.9 48.5 1,214

Development region
Eastern 70.4 67.8 50.7 583
Central 75.5 63.8 50.0 750
Western 66.4 67.7 46.9 436
Mid-western 76.4 70.0 57.4 295
Far-western 81.3 76.7 67.2 197

Subregion
Eastern Mountain 60.5 81.4 52.3 33
Central Mountain 82.1 84.6 70.9 59
Western Mountain 79.8 55.8 48.1 59
Eastern Hill 70.6 87.0 63.1 161
Central Hill 65.9 84.8 56.5 278
Western Hill 63.7 68.4 45.9 235
Mid-western Hill 77.1 68.2 58.7 143
Far-western Hill 80.0 71.1 62.8 80
Eastern Terai 71.1 58.7 45.5 389
Central Terai 81.0 46.8 42.6 413
Western Terai 69.6 66.8 48.1 201
Mid-western Terai 73.8 73.4 56.8 126
Far-western Terai 84.8 92.4 80.4 85

Total 73.1 67.5 52.1 2,261
Fertility * 55
4
FERTILITY


A major objective of the 2001 NDHS is to examine fertility levels, trends, and differentials in
Nepal. This is important in view of the governments policy to reduce the total fertility rate to 4.2 by
the end of the Ninth Plan in the year 2002 and bring a balance between population growth and
economic development. To meet this objective, ever-married women age 15-49 were asked about
their pregnancy histories. Each woman was asked the number of sons and daughters living with her,
the number of sons and daughters living elsewhere, the number of sons and daughters who died, and
the number of pregnancies that did not result in a live birth. The woman was then asked to provide a
complete pregnancy history including information such as the month and year of all live and nonlive
births, sex of live births, and survival status. The structure of these questions is designed to improve
the completeness and accuracy of the information.

This chapter examines current fertility, differentials and trends in fertility, and cumulative
fertility in Nepal. It also examines the length of birth intervals, age at first birth, and childbearing
among adolescents. As is standard practice, the analyses of fertility presented here are based only on
live births. The 2001 NDHS obtained reproductive histories only from ever-married women. It is
assumed that births outside marriage are negligible in Nepal and that the pregnancies experienced by
ever-married women represent all pregnancies.

4.1 CURRENT FERTILITY

The level of current fertility is one of the most important indicators for health and family
planning policymakers and professionals in Nepal because of its direct relevance to the population
policy and programs. Table 4.1 presents age-specific fertility rates (ASFR),
1
the total fertility rate
(TFR) for women age 15-49, the general fertility rate (GFR) for women age 15-44, and the crude
birth rate (CBR), by residence. All these rates pertain to the three-year period preceding the survey.
A three-year rate is chosen because it provides current information, without unduly increasing
sampling error. The TFR is the sum of the ASFRs and can be interpreted as the number of children a
woman would have by the end of her childbearing age if she experienced the prevailing ASFRs. The
GFR is defined as the total annual number of births per 1,000 women age 15-44, and the CBR is
defined as the total number of live births in a year per 1,000 persons.

1
Numerators of the ASFRs are calculated as the total number of live births that occurred in the period 1-36 months
preceding the survey (determined by the date of interview and the date of birth of the child), and classified by the age (in
five-year age groups) of the mother at the time of the birth (determined by the mothers date of birth). The denominators
of the rates are the number of woman-years lived in each of the five-year age groups during the 1-36 months preceding
the survey. Rates are expressed per 1,000 women. Since only ever-married women were interviewed in the 2001 NDHS,
the number of women in the denominators of the rates was inflated by factors calculated from information in the
Household Questionnaire on proportions ever-married in order to produce a count of all women. An implicit assumption
in this calculation is that never-married women have not given birth.
56 * Fertility

The TFR for Nepalese women age 15-49 is 4.1 births per woman. There is a large difference
in fertility by urban-rural residence; the TFR among urban women (2.1) is 2.3 children less than that
among rural women (4.4). The age pattern of fertility indicates that Nepalese women have high
fertility in the early part of the childbearing period. At the current ASFRs, a woman in Nepal will
have given birth to about three children by age 30. The ASFRs in both urban and rural areas peak at
age 20-24. In urban areas, fertility rates decline rapidly after age 24, whereas in rural areas the
fertility decline by age is more gradual. The ASFRs are consistently lower in urban areas than in
rural areas, and women in urban areas of Nepal seem to almost stop having children after age 40. The
GFRs for urban areas, rural areas, and for all of Nepal are 81, 156, and 148 per 1,000 women age 15-
44, respectively. The CBR for the three-year period before the survey is 34 per 1,000 population.
Both these summary rates also indicate higher fertility in rural than in urban areas.


Table 4.1 Current fertility


Age-specific and cumulative fertility rates, the
general fertility rate, and the crude birth rate for
the three years preceding the survey, by urban-
rural residence, Nepal 2001



Residence



Age group Urban Rural Total


15-19 72 114 110


20-24 153 261 248


25-29 102 217 205


30-34 60 146 136


35-39 28 87 81


40-44 2 38 34


45-49 0 8 7





TFR 2.1 4.4 4.1


GFR 81 156 148


CBR 20.6 34.9 33.5


TFR: Total fertility rate for ages 15-49, expressed
per woman
GFR: General fertility rate (births divided by the
number of women age 15-44), expressed per 1,000
women
CBR: Crude birth rate, expressed per 1,000
population
Note: Rates for age group 45-49 may be slightly
biased due to truncation.

FERTILITY DIFFERENTIALS AND TRENDS

Table 4.2 summarizes the current level of fertility by area of residence, ecological zone,
development region, and education. The TFR in the mountains (4.8) is highest among the three
ecological zones, while the TFR in the hills (4.0) is about the same as in the terai ecological zone
(4.1). By to development region, women in the Western and Eastern regions have on average one
child fewer than women in the Mid-western and Far-western regions and half a child fewer than
women in the Central region. There is a strong association between fertility and education, with the
TFR declining as the level of education increases. The TFR of women with no education (4.8) is
more than double that of women with at least an SLC level of education (2.1).
Fertility * 57

The percentage of women who reported themselves as currently pregnant is also given in
Table 4.2. Since women in the early stages of pregnancy may not be aware that they are pregnant and
because some women may not want to reveal that they are pregnant, this percentage may be
underestimated. Seven percent of women reported that they were pregnant at the time of the survey.
The proportion pregnant is nearly twice as high in rural areas as in urban areas. The percentage of
women who are pregnant is generally consistent with current fertility levels for each major
population subgroup in that groups with higher fertility also tend to have higher percentages of
women currently pregnant.

Table 4.2 also shows the mean number of children ever born to women age 40-49, which is a
measure of the average lifetime fertility experience of women age 40-49 (completed fertility).
Although this measure is susceptible to omission, comparison of completed fertility among women
age 40-49 with the current TFR indicates fertility decline for all major subgroups of the population.
Overall, the results in Table 4.2 suggest that there has been a 24 percent decline in fertility levels
during the past 20-25 years. Both the current and lifetime fertility indicate that fertility is lower in
urban areas and among the more educated.


Table 4.2 Fertility by background characteristics


Total fertility rate for the three years preceding the survey,
percentage of all women age 15-49 currently pregnant, and
mean number of children ever born to women age 40-49
years, by background characteristics, Nepal 2001


Background
characteristic
Total
fertility
rate
1

Percentage
currently
pregnant
1

Mean number
of children
ever born to
women age
40-49
Residence



Urban 2.1 4.3 4.5


Rural 4.4 7.4 5.5





Ecological zone


Mountain 4.8 7.2 6.1


Hill 4.0 7.3 5.4


Terai 4.1 6.9 5.3





Development region


Eastern 3.8 6.6 4.9


Central 4.3 7.3 5.4


Western 3.5 6.3 5.3


Mid-western 4.7 7.4 6.4


Far-western 4.7 8.7 6.0





Education


No education 4.8 7.5 5.6


Primary 3.2 6.7 4.5


Some secondary 2.3 6.1 3.7


SLC and above 2.1 5.7 2.6





Total 4.1 7.1 5.4


SLC = School Leaving Certificate

1
Women age 15-49 years

58 * Fertility

Comparing the TFR obtained from three earlier surveys with the TFR obtained from the 2001
NDHS indicates a steady decline in fertility (Table 4.3 and Figure 4.1). Direct estimates of fertility
for the three years preceding the survey have been used in this comparison because a three-year rate
is more robust than rates based on a shorter or longer period. There was a 6 percent decline in TFR
between 1984-1986 and 1989-1991, compared with a 3 percent decline between 1989-1991 and
1993-1995. Between 1994-1996 and 1998-2000, the percentage decline in fertility was 12 percent.
Fertility trends have to be interpreted within the context of data quality and sample size. A
discussion of these issues in relation to earlier surveys is beyond the scope of this report. As such,
the fertility trend shown in Table 4.3 and Figure 4.1 has to be interpreted with caution.



Table 4.3 Trends in fertility


Age-specific fertility rates (per 1,000 women) and total fertility rates,
Nepal 2001


Age group
NFFS 1986
a
(1984-1986)
NFHS 1991
a
(1989-1991)
NFHS 1996
b
(1993-1995)
NDHS 2001
(1998-2000)


15-19 99 101 127 110


20-24 261 263 266 248


25-29 230 230 229 205


30-34 200 169 160 136


35-39 114 117 94 81


40-44 68 55 37 34


45-49 49 26 15 7





TFR 5.11 4.79 4.64 4.10


Note: Rates are for the three years preceding the survey.
a
Pradhan, 1995:32
b
Pradhan et al., 1997:37


5.1
4.8
4.6
4.1
1984-1986
(NFFS 1986)
1989-1991
(NFHS 1991)
1993-1995
(NFHS 1996)
1998-2000
(NDHS 2001)
0
1
2
3
4
5
6
Births per woman
Figure 4.1 Trends in Total Fertility Rate 1984-2001
Note: Rates are for the three years preceding the survey.


Fertility * 59
Information from birth histories in the 2001 NDHS allows the calculation of ASFRs for
specified periods before the survey, which in turn
provide further evidence of recent fertility decline.
However, in situations in which the placement of
births in time may not be reported correctly, trends
in fertility could be distorted. Furthermore, ASFRs
are progressively truncated as one moves into the
past. Nevertheless, the results presented in Table
4.4 indicate an 18 percent decline in fertility among
women age 15-29 from 3.6 births per woman
during the period 15-19 years before the survey to
2.9 births per woman during the period 0-4 years
before the survey. The largest decline in fertility
(14 percent) took place between 5-9 and 0-4 years
before the survey, versus only a 6 percent decline in
fertility between 10-14 and 5-9 years before the
survey and no change between 15-19 and 10-14
years before the survey.

4.2 PREGNANCY OUTCOMES

The 2001 NDHS collected complete pregnancy histories from women and therefore provides
information on pregnancy outcomes. It is important to note that collecting pregnancy histories is
comparatively more difficult than collecting birth histories retrospectively, especially for information
on pregnancies that were miscarried within the first few months after conception. Therefore, the total
number of pregnancies and abortions are likely to be underestimated and caution should be exercised
while interpreting these data. Stillbirths are probably more completely reported than abortions.

Table 4.5 presents the pregnancy outcomes among ever-married women 0-9 years before the
survey by age of the mother and urban-rural residence. Overall, 92 percent of pregnancies result in a
live birth and 8 percent of pregnancies end as nonlive births2 percent as stillbirths, 5 percent as
spontaneous abortions, and 1 percent as induced abortions. There is little variation in pregnancy
outcomes across age groups, although older women (age 35 and above) are slightly more likely to
have pregnancies resulting in nonlive births. Similar patterns are observed by urban-rural residence,
with 91 percent of pregnancies in the urban areas and 93 percent of pregnancies in the rural areas
resulting in live births. Abortions are more common in urban areas than in rural areas, especially
induced abortions.
Table 4.4 Trends in age-specific fertility rates
Age-specific fertility rates for five-year periods
preceding the survey, by mother's age at the time of
the birth, Nepal 2001


Number of years preceding survey


Mother's age
at birth 0-4 5-9 10-14 15-19
15-19 116 148 144 136
20-24 260 289 307 303
25-29 213 247 274 283
30-34 144 180 212 [231]
35-39 84 125 [143]
40-44 36 [56]
45-49 [8]
Note: Age-specific fertility rates are per 1,000
women. Estimates in brackets are truncated.

60 * Fertility

Table 4.5 Pregnancy outcome
Percent distribution of all pregnancies among ever-married women in the ten years preceding
the survey by pregnancy outcome, according to age at end of pregnancy and residence, Nepal
2001


Pregnancy outcome


Age at end
of pregnancy
Spontaneous
abortion
Induced
abortion Still birth Live birth Total
Number
of
pregnancies

URBAN

<20 5.5 0.6 2.0 91.9 100.0 257
20-24 5.9 1.8 1.5 90.7 100.0 406
25-29 2.8 3.3 1.1 92.8 100.0 251
30-34 5.0 4.0 2.7 88.3 100.0 120
35-39 7.0 4.0 1.5 87.6 100.0 61

Total 5.2 2.3 1.6 90.9 100.0 1,103
RURAL

<20 5.2 0.3 2.1 92.5 100.0 2,657
20-24 4.2 0.4 2.1 93.3 100.0 4,684
25-29 3.7 0.7 2.4 93.3 100.0 3,301
30-34 5.6 0.8 1.8 91.8 100.0 1,999
35-39 6.8 1.2 2.7 89.3 100.0 1,126
40-44 8.5 1.9 2.6 87.0 100.0 317

Total 4.8 0.6 2.2 92.5 100.0 14,106
TOTAL

<20 5.2 0.3 2.1 92.4 100.0 2,915
20-24 4.3 0.5 2.1 93.1 100.0 5,090
25-29 3.6 0.9 2.3 93.2 100.0 3,551
30-34 5.6 1.0 1.8 91.6 100.0 2,119
35-39 6.8 1.3 2.7 89.2 100.0 1,187
40-44 8.7 2.1 2.6 86.6 100.0 326

Total 4.8 0.7 2.1 92.3 100.0 15,210
Note: Pregnancy outcomes for age groups 40-44 (in urban only) and 45-49 are not shown
because they are based on fewer than 25 pregnancies



4.3 CHILDREN EVER BORN AND LIVING

Table 4.6 presents the distribution of all women and currently married women by age and
number of children ever born (CEB) and the mean number of living children by age. Lifetime
fertility reflects the accumulation of births over the past 30 years and, therefore, its relevance to the
current situation is limited; nevertheless, information on the mean number of children ever born is
useful in examining the variation among different age groups.

The mean number of children ever born for all wo-men is 2.7, which means that on average,
Nepalese women age 15-49 have had fewer than 3 births, while currently married women have 3.3
births on average. Allowing for child mortality, Nepalese women have on average 2.3 living
children, while currently married women have an average of 2.8 living children. In contrast,
currently married women age 45-49 have given birth to an average of 5.9 children, of whom 4.6
survived. Therefore, currently married women at the end of their reproductive careers (age 45-49)
lost 23 percent of their children due to mortality. The comparative figure estimated in the 1996
NFHS was 26 percent, implying a slight shift toward lower mortality among children of currently
married women during their reproductive span in more recent years.


Fertility * 61

Table 4.6 Children ever born and living
Percent distribution of all women and currently married women by number of children ever born, and mean number of children ever born
and mean number of living children, according to age group, Nepal 2001


Number of children ever born


Age 0 1 2 3 4 5 6 7 8 9 10+

Total

Number
of
women
Mean
number of
children
ever born
Mean
number of
living
children

ALL WOMEN

15-19 83.8 14.3 1.9 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,335 0.18 0.16
20-24 29.5 27.0 28.8 11.9 2.2 0.6 0.0 0.0 0.0 0.0 0.0 100.0 2,001 1.32 1.20
25-29 8.3 9.1 26.7 27.2 19.1 7.4 2.0 0.2 0.0 0.0 0.0 100.0 1,744 2.71 2.43
30-34 4.5 4.6 15.3 22.0 22.6 15.7 9.2 4.1 1.5 0.4 0.1 100.0 1,464 3.71 3.24
35-39 4.2 3.3 6.2 18.6 21.4 17.0 14.0 6.5 5.9 1.6 1.4 100.0 1,191 4.48 3.74
40-44 2.9 2.7 6.4 11.6 19.0 15.5 13.6 10.9 8.2 5.1 4.0 100.0 1,042 5.16 4.26
45-49 3.1 2.7 4.3 9.5 13.3 17.2 14.6 11.5 6.9 7.4 9.6 100.0 849 5.71 4.37

Total 27.0 11.2 14.0 13.7 12.0 8.3 5.7 3.3 2.2 1.3 1.3 100.0 10,626 2.71 2.29
CURRENTLY MARRIED WOMEN

15-19 59.6 35.4 4.7 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 930 0.46 0.41
20-24 14.6 32.6 35.0 14.4 2.7 0.7 0.0 0.0 0.0 0.0 0.0 100.0 1,643 1.60 1.45
25-29 3.4 9.4 28.0 28.8 20.2 8.0 2.2 0.1 0.0 0.0 0.0 100.0 1,625 2.86 2.57
30-34 1.9 4.0 15.5 23.0 23.2 16.4 9.7 4.2 1.6 0.4 0.1 100.0 1,377 3.84 3.36
35-39 2.0 2.7 5.9 18.6 22.2 17.7 14.4 6.9 6.2 1.7 1.5 100.0 1,099 4.64 3.89
40-44 1.3 2.2 5.8 11.5 19.1 16.3 13.8 11.2 8.9 5.5 4.3 100.0 936 5.34 4.43
45-49 1.8 2.0 3.5 8.7 13.4 17.4 14.9 12.3 7.5 8.1 10.2 100.0 732 5.94 4.56

Total 11.1 13.6 17.2 16.8 14.5 10.1 6.8 4.0 2.7 1.6 1.6 100.0 8,342 3.29 2.79


The distribution of children ever born by age shows that early childbearing is still common in
Nepal; 16 percent of all women age 15-19 have already had at least one birth.

Voluntary childlessness is rare in Nepal, and currently married women with no live births are
likely to be those who are unable to bear children. The level of childlessness among married women
at the end of their reproductive careers can therefore be used as an indicator of the level of primary
sterility. In Nepal, primary sterility among older currently married women is less than 2 percent.

4.4 BIRTH INTERVALS

Short birth intervals are associated with an increased risk of death for mother and child. This
is particularly true for babies born less than 24 months after a previous birth. Table 4.7 presents
the percent distribution of births in the five years preceding the survey by the number of months
since the previous birth according to background characteristics. Twenty-three percent of births
occurred within 24 months of a previous birth, and the median birth interval is 32 months. The long
period of breastfeeding in Nepal, which is an average of 29 months (see Chapter 10), and the
corresponding long period of postpartum amenorrhea, which is an average of 11 months (see Chapter
6), are likely to contribute to the relatively high percentage of births occurring after an interval of 24
months or more.
62 * Fertility

Table 4.7 Birth intervals
Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth,
according to background characteristics, Nepal 2001


Months since preceding birth



Background
characteristic 7-17 18-23 24-35 36-47 48+ Total
Median
number of
months since
preceding birth
Number of
non-first
births

Age

15-19 30.9 29.1 36.7 2.1 1.2 100.0 21.9 47
20-29 9.2 16.9 41.1 20.2 12.5 100.0 29.9 2,991
30-39 6.6 12.1 34.0 21.8 25.6 100.0 35.0 1,883
40-49 5.6 7.1 24.9 21.9 40.5 100.0 41.5 383

Birth order
2-3 8.4 15.5 37.2 20.3 18.6 100.0 31.4 2,781
4-6 7.9 13.9 37.5 21.1 19.6 100.0 32.3 1,928
7+ 7.9 12.8 37.9 21.7 19.7 100.0 32.2 596

Sex of preceding birth
Male 8.0 14.4 37.1 20.7 19.8 100.0 32.1 2,582
Female 8.4 14.8 37.7 20.7 18.4 100.0 31.6 2,723

Survival of preceding birth
Living 6.3 14.1 38.3 21.6 19.7 100.0 32.6 4,667
Dead 22.1 18.2 30.8 14.1 14.8 100.0 26.5 639

Residence
Urban 10.0 17.3 30.9 21.5 20.2 100.0 32.3 284
Rural 8.1 14.5 37.7 20.7 19.0 100.0 31.8 5,021

Ecological zone
Mountain 9.0 13.5 37.4 22.0 18.0 100.0 31.9 423
Hill 8.3 14.4 37.0 21.0 19.3 100.0 32.0 2,173
Terai 8.0 15.0 37.6 20.3 19.1 100.0 31.6 2,710

Development region
Eastern 9.4 15.9 35.0 19.5 20.3 100.0 31.0 1,226
Central 9.0 14.8 37.3 20.4 18.5 100.0 31.3 1,738
Western 7.4 13.5 35.1 22.9 21.0 100.0 33.8 931
Mid-western 6.8 13.9 44.4 19.2 15.8 100.0 31.2 823
Far-western 6.4 14.1 36.3 23.1 20.0 100.0 33.4 588

Subregion
Eastern Mountain 12.7 18.2 32.7 17.3 19.1 100.0 29.7 84
Central Mountain 10.3 9.9 43.1 19.8 17.0 100.0 30.9 134
Western Mountain 6.7 14.0 35.7 25.3 18.3 100.0 33.0 206
Eastern Hill 10.2 14.0 36.9 20.6 18.3 100.0 31.1 433
Central Hill 9.8 15.0 34.4 19.4 21.4 100.0 31.2 492
Western Hill 7.8 14.5 32.3 23.6 21.8 100.0 34.3 479
Mid-western Hill 7.3 15.1 45.3 18.3 14.1 100.0 30.7 510
Far-western Hill 5.0 12.6 34.7 25.3 22.5 100.0 35.2 258
Eastern Terai 8.5 16.8 34.0 19.1 21.6 100.0 31.0 710
Central Terai 8.5 15.3 37.9 20.9 17.4 100.0 31.3 1,112
Western Terai 6.9 12.5 38.2 22.2 20.2 100.0 33.2 451
Mid-western Terai 6.9 11.4 44.8 18.5 18.4 100.0 31.8 236
Far-western Terai 6.6 16.1 39.4 19.6 18.3 100.0 31.7 201

Education
No education 7.9 14.2 37.5 21.1 19.4 100.0 32.1 4,234
Primary 8.2 16.4 37.9 19.7 17.9 100.0 30.7 649
Some secondary 10.0 17.0 36.8 19.2 17.0 100.0 30.8 317
SLC and above 15.7 14.8 30.9 19.2 19.5 100.0 28.7 105

Total 8.2 14.6 37.4 20.7 19.1 100.0 31.8 5,305
Note: First- births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that
ended in a live birth.
SLC = School Leaving Certificate

Fertility * 63
The median birth interval increases with the age of the mother from 22 months among births
to mothers age 15-19 to 42 months among births to mothers age 40-49. The relatively high
prevalence of short birth intervals among births to younger women indicates that women generally
want to complete their desired family size quickly

The survival status of the previous birth is strongly associated with the length of the
preceding birth interval. The median birth interval is more than six months shorter for children
whose previous sibling died compared with children whose previous sibling survived. Twenty-
two percent of children whose preceding sibling died were born after an interval of less than 18
months, compared with only 6 percent among children whose preceding sibling survived. More than
40 percent of children whose preceding sibling died were born within 24 months of the previous
birth, compared with 20 percent of those whose preceding sibling survived.

The median birth interval is slightly longer for births in the Western region and in the Far-
western hill subregion.

The median birth interval decreases with increase in level of education. Births to women
with no education have a median preceding birth interval of 32 months, while it is 29 months for
women with SLC and higher education.

4.5 AGE AT FIRST BIRTH

Age at the onset of childbearing is an important demographic indicator, since early
childbearing adversely affects the health of mother and child. The proportion of women who
become mothers before age 20 is a measure of the magnitude of adolescent fertility, which is a major
health and social concern in many countries. Furthermore, in many countries, postponement of first
births, reflecting an increase in age at marriage, has made a large contribution to overall fertility
decline.

Table 4.8 presents the distribution of women by age at first birth. The median age at first
birth is not shown for women age 15-19 because fewer than 50 percent have had a birth by the time
of the survey. The median age at first birth is about 20 years across all age cohorts, indicating
virtually no change in the age at first birth. About 1 percent of women give birth by age 15, and


Table 4.8 Age at first birth
Among all women who have given birth, percentage who had their first birth by specific exact ages, and median
age at first birth, by current age, Nepal 2001


Age at first birth


Current age 15 18 20 22 25
Percentage
who have
never given
birth

Number
of
women
Median
age at
first birth

15-19 0.2 na na na na 83.8 2,335 a
20-24 0.8 26.0 51.3 na na 29.5 2,001 19.9
25-29 1.3 24.0 54.1 75.2 88.5 8.3 1,744 19.7
30-34 0.9 23.8 51.5 74.0 87.9 4.5 1,464 19.9
35-39 1.3 24.1 50.2 70.6 87.4 4.2 1,191 20.0
40-44 1.0 23.7 50.1 70.6 86.9 2.9 1,042 20.0
45-49 1.2 23.7 47.5 69.8 87.4 3.1 849 20.2
na = Not applicable
a
Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group



64 * Fertility
about one-quarter have had a birth by age 18. Half of women have given birth by age 20, and at least
70 percent of women in all age cohorts had their first birth by age 22. Almost 90 percent of
Nepalese women had their first birth by age 25.

Table 4.9 summarizes the median age at first birth for different age groups and compares the
age at entry into motherhood for selected subgroups of the population. Women residing in the terai
have a lower median age at first birth than women residing in the mountains and hills. The median
age at first birth is lower among women in the Far-western development region. Within the
subregion, women residing in the Far-western terai have the lowest median age at first birth.
Women with no education or only primary education give birth to their first child at least three years
earlier than women who have at least an SLC level of education.


Table 4.9 Median age at first birth


Median age at first birth among women age 25-49 years, by current age and
background characteristics, Nepal 2001


Current age



Background
characteristic 25-29 30-34 35-39 40-44 45-49 25-49
Residence



Urban 21.3 19.9 19.8 19.9 20.4 20.2


Rural 19.7 19.9 20.0 20.0 20.2 19.9





Ecological zone


Mountain 20.0 20.2 21.1 21.3 21.3 20.6


Hill 20.2 20.4 20.8 20.6 20.6 20.5


Terai 19.4 19.4 19.5 19.5 19.6 19.4





Development region


Eastern 20.8 20.8 21.1 20.9 20.9 20.9


Central 19.9 19.9 20.0 19.6 20.3 19.9


Western 20.4 20.7 20.8 20.2 20.2 20.5


Mid-western 20.1 19.5 19.6 20.2 19.8 19.9


Far-western 19.7 19.2 19.2 19.7 20.5 19.5





Subregion


Eastern Mountain 22.8 22.3 22.6 22.9 23.0 22.7


Central Mountain 20.0 20.4 20.7 21.6 21.6 20.8


Western Mountain 20.0 19.7 20.8 20.5 20.3 20.2


Eastern Hill 21.1 21.4 23.5 22.5 22.2 21.9


Central Hill 21.1 20.6 21.2 20.3 21.0 20.8


Western Hill 20.9 20.9 21.6 20.3 20.2 20.9


Mid-western Hill 20.2 19.7 19.2 21.2 20.4 20.1


Far-western Hill 19.9 19.9 18.9 20.2 20.9 19.7


Eastern Terai 20.6 20.4 20.1 20.4 19.8 20.3


Central Terai 19.4 19.2 19.6 19.2 19.8 19.4


Western Terai 19.6 19.9 19.2 20.0 20.2 19.7


Mid-western Terai 20.0 19.2 19.9 18.9 18.8 19.5


Far-western Terai 18.9 18.5 18.9 19.2 19.7 18.9





Education


No education 19.4 19.7 19.9 20.0 20.2 19.8


Primary 19.6 19.9 20.5 19.6 20.0 19.8


Some secondary 20.4 20.2 20.9 19.8 20.5 20.3


SLC and above 22.8 23.5 21.5 23.4 21.8 22.9





Total 19.7 19.9 20.0 20.0 20.2 19.9


SLC = School Leaving Certificate
Fertility * 65
4.6 ADOLESCENT FERTILITY

Adolescent fertility is a major social and health concern. Teenage mothers are more likely to
suffer from severe complications during pregnancy and childbirth, which can be detrimental to the
health and survival of both mother and child. Table 4.10 presents the percentage of women age 15-
19 who are mothers or who are pregnant with their first child by selected background characteristics.
Overall, 21 percent of adolescent women age 15-19 are already mothers or are pregnant with their
first child. The proportion of teenage women who have started childbearing increases with age from
2 percent among women age 15 to 41 percent among women age 19.

In Nepal, 23 percent of rural adolescents have begun childbearing, compared with only
13 percent of urban adolescents. Only 17 percent of adolescents living in the hills have begun
childbearing, compared with 20 percent in the mountains and 26 percent in the terai areas.
Regionally, the highest level of adolescent childbearing is observed in the Central development
region (24 percent), while the lowest is found in the Western development region (16 percent). The
proportion of adolescents who have begun childbearing declines with increasing education, from
32 percent among those with no education to 8 percent among those with SLC and higher levels of
education.




Table 4.10 Teenage pregnancy and motherhood
Percentage of all women age 15-19 who are mothers or pregnant with their first child,
by background characteristics, Nepal 2001


Percentage who are:



Background
characteristic Mothers
Pregnant with
first child
Percentage
who have
begun
childbearing
Number
of
women

Age
15 0.5 1.0 1.5 361
16 3.9 5.4 9.3 451
17 12.6 4.9 17.5 571
18 25.3 8.8 34.0 510
19 35.9 4.6 40.5 442

Residence
Urban 10.1 2.5 12.6 249
Rural 17.0 5.5 22.5 2,087

Ecological zone
Mountain 15.8 3.9 19.7 157
Hill 12.1 4.9 17.0 1,041
Terai 20.0 5.6 25.5 1,144

Development
region

Eastern 16.5 6.1 22.6 579
Central 19.5 4.3 23.8 677
Western 11.9 4.2 16.1 501
Mid-western 16.2 5.8 22.0 354
Far-western 15.5 7.0 22.5 220

Education
No education 24.9 6.6 31.5 842
Primary 14.3 5.3 19.6 662
Some secondary 9.7 3.6 13.2 706
SLC and above 4.3 4.0 8.3 138

Total 16.2 5.2 21.4 2,335
SLC = School Leaving Certificate
Family Planning * 67

5
FAMILY PLANNING



This chapter begins with an appraisal of the knowledge of different contraceptive methods
before moving on to a consideration of past and current prevalence. For users of periodic abstinence,
knowledge of the ovulatory cycle is examined, while for those relying on sterilization, the timing of
adoption of the method is reviewed. Special attention is focused on source of contraception,
informed choice, nonuse, and intention to use in the future. The chapter also contains information on
exposure to media coverage on family planning and ends with an analysis of interspousal discussions
on family planning. All these topics are of practical use to policy and program administrators in the
formulation of effective family planning strategies. Although the main focus is on women, results
from the male survey will also be presented since men play an important role in the realization of
reproductive goals. Wherever possible, comparisons are also made with findings from previous
surveys in order to evaluate family planning in Nepal over time.

5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS

Acquiring knowledge of contraceptive methods is an important precondition toward gaining
access to and then using a suitable contraceptive method in a timely and effective manner. The
ability to name or recognize a family planning method is a nominal test of the respondents
knowledge and not a measure of how much they might know about the method. However,
knowledge of specific methods is a precursor to use.

Information on knowledge of contraception was collected by first asking the respondent to
name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to
mention a particular method spontaneously, the interviewer then described the method and asked
whether the respondent recognized it. Eight modern family planning methodsfemale and male
sterilization, the pill, the IUD, injectables, implants, condoms, and vaginal methods (foam/jelly)
were described, as well as two methods categorized as traditionalperiodic abstinence and
withdrawal. Folk methods could be mentioned spontaneously by respondents and include such
methods as plants and herbs.

In Table 5.1, knowledge of contraceptive methods is presented for ever-married and currently
married women and men by specific methods. Findings from the 2001 NDHS show that knowledge
of at least one modern method of family planning is nearly universal in Nepal, with little difference
between women and men. The most widely known modern contraceptive methods among both ever-
married and currently married women are female sterilization (99 percent), male sterilization
(98 percent), injectables (97 percent), the pill (93 percent), and condoms (91 percent). Four in five
women know of implants, a little more than one in two women have heard of the IUD, while two in
five women have heard of vaginal methods. This pattern is similar for ever-married and currently
married men except that men are relatively more likely than women to have heard of condoms,
vaginal methods, and the IUD and are less likely to have heard of injectables and pills. A greater
proportion of women and men reported knowing a modern method than a traditional method. This is
more pronounced in the case of women, only 55 percent of them know of any traditional method.
Reported knowledge of traditional methods is much higher among men (more than 80 percent). One
of the reasons for the low reporting of knowledge of a traditional method may be that these methods
are not included in the government family planning program and women may be reluctant to mention
them since they are not widely accepted.
68 * Family Planning

There is little difference in the percentage who have heard of at least one method of
contraception by background characteristics (data not shown). The high level of knowledge could be
attributed to the successful dissemination of family planning messages through the mass media.

Table 5.1 Knowledge of contraceptive methods
Percentage of ever-married women, of currently married women, of
ever-married men, and of currently married men who know any
contraceptive method, by specific method, Nepal 2001


Method
Ever-
married
women
Currently
married
women
Ever-
married
men
Currently
married
men

Any method 99.5 99.5 99.4 99.6

Any modern method 99.5 99.5 99.4 99.6
Female sterilization 99.1 99.1 98.4 98.6
Male sterilization 98.2 98.2 98.2 98.4
Pill 93.2 93.4 89.8 90.3
IUD 54.4 54.7 58.6 59.3
Injectables 97.3 97.3 93.7 94.2
Implants 79.6 79.8 71.4 72.1
Condom 90.8 91.0 96.8 97.1
Foam/jelly 39.9 40.2 53.7 54.5

Any traditional method 54.9 55.4 80.3 81.0
Periodic abstinence 34.9 35.1 62.3 62.8
Withdrawal 40.5 41.1 69.7 70.7
Folk method 6.4 6.4 3.0 3.1

Mean number of methods
known 7.3 7.4 8.0 8.0


Number of women 8,726 8,342 2,261 2,198

5.2 EVER USE OF CONTRACEPTION

Data on ever use has special significance since it reveals the cumulative success of programs
promoting the use of family planning among couples. Ever use refers to use of a method at any time,
with no distinction between past and present use. In the 2001 NDHS, respondents who had heard of
a method of family planning were asked whether they had ever used it.

Table 5.2 shows the percent distribution of ever-married and currently married women who
have ever used family planning by specific method and age. Information on ever-use by method is
also presented for ever-married and currently married men. Fifty-four percent of currently married
women and 69 percent of currently married men had used a method in the past, and 50 percent of
currently married women and 63 percent of currently married men have used a modern method.
Among currently married women, the most commonly used modern methods were injectables
(21 percent), female sterilization (15 percent), pills and condoms (12 percent each), and male
sterilization (7 percent). Among currently married men, use of condoms (35 percent) was highest,
followed by injectables (22 percent), female sterilization (17 percent), and pills (14 percent). The
large difference between men and women in ever use of modern contraception is almost entirely due
to the greater reported use of condoms among men.
Family Planning * 69

Ever use of contraception varies with womens age. The pattern of ever use is curvilinear,
with use being lowest among women in the youngest age group (15-19), increasing with age, and
reaching a plateau among women in their thirties before declining. The level of ever-use of any
method among currently married women rises to a high of 68 percent among the 30-39 age group
and then declines to 54 percent among women age 45-49. Ever use of any modern method by age
among women follows a similar pattern.

Table 5.2 Ever use of contraception
Percentage of ever-married and currently married women who have ever used any contraceptive method, by specific method and age,
and percentage of ever-married and currently married men who have ever used any contraceptive method, by specific method, Nepal
2001

Modern method Traditional method

Age
Any
method
Any
modern
method
Female
sterili-
zation
Male
sterili-
zation Pill IUD
Inject-
ables Implants Condom
Foam/
jelly
Any
tradi-
tional
method
Periodic
absti-
nence
With-
drawal
Folk
method
Number
of
women/
men

EVER-MARRIED WOMEN (MEN)
15-19 21.7 17.6 0.0 0.0 3.7 0.1 6.3 0.0 10.4 0.2 7.6 1.6 6.9 0.1 941
20-24 42.4 37.7 4.0 1.7 8.4 0.9 19.1 1.0 16.0 0.9 12.7 4.6 10.0 0.2 1,658
25-29 56.9 52.4 14.2 4.9 13.5 1.7 25.8 1.7 14.3 0.7 14.8 5.6 11.5 0.6 1,666
30-34 66.6 62.8 19.0 9.4 16.3 1.7 29.9 2.2 12.8 1.2 15.2 6.7 10.8 0.9 1,427
35-39 65.5 61.8 24.5 9.1 15.8 1.6 24.5 1.1 10.7 1.6 12.3 5.5 8.3 0.7 1,168
40-44 62.0 58.2 25.8 10.2 13.9 0.5 18.4 1.3 6.5 0.6 9.9 5.4 5.8 1.2 1,030
45-49 50.9 46.8 20.5 11.8 10.6 0.3 10.9 0.3 3.9 0.4 7.4 3.4 3.5 1.8 837

Total:
women

53.1

49.0

14.9

6.4

12.0

1.1

20.6

1.2

11.6

0.8

12.1

4.9

8.7

0.7

8,726


Total:
men

67.8

61.3

16.8

6.7

13.2

1.0

21.8

1.4

34.3

2.2

28.5

17.2

18.4

0.9

2,261

CURRENTLY MARRIED WOMEN (MEN)
15-19 21.9 17.7 0.0 0.0 3.8 0.1 6.4 0.0 10.4 0.2 7.6 1.6 7.0 0.1 930
20-24 42.5 37.8 4.1 1.8 8.5 0.9 19.1 1.1 16.1 0.9 12.8 4.6 10.1 0.2 1,643
25-29 57.8 53.2 14.4 5.0 13.6 1.7 26.1 1.8 14.6 0.7 15.1 5.8 11.8 0.6 1,625
30-34 68.0 64.1 19.3 9.7 16.6 1.8 30.6 2.3 13.1 1.2 15.7 7.0 11.1 1.0 1,377
35-39 68.0 64.1 25.5 9.4 16.4 1.7 25.8 1.2 11.2 1.7 12.9 5.8 8.6 0.7 1,099
40-44 65.2 61.3 26.7 10.9 14.7 0.5 19.5 1.4 7.0 0.7 10.8 5.9 6.2 1.2 936
45-49 54.1 49.5 21.1 12.8 11.3 0.4 12.0 0.4 4.3 0.5 8.0 3.8 3.8 1.9 732

Total:
women

54.3

50.0

15.0

6.5

12.3

1.1

21.3

1.3

12.0

0.9

12.5

5.1

9.1

0.7

8,342


Total:
men

69.0

62.5

17.2

6.8

13.5

1.0

22.3

1.4

34.9

2.2

29.0

17.5

18.7

0.9

2,198


5.3 CURRENT USE OF CONTRACEPTION

Current use of contraception is defined as the proportion of women and men who reported
they were using a family planning method at the time of interview. The level of current use is the
most widely used and valuable measure of the success of family planning programs. Table 5.3
shows the percent distribution of currently married women who are currently using specific family
planing methods by age. Information on current use by method is also shown for men.



70 * Family Planning



Table 5.3 Current use of contraception
Percent distribution of currently married women by contraceptive method currently used, according to age, and percent distribution of currently married men by
contraceptive method currently used, Nepal 2001

Modern method Traditional method

Age
Any
method
Any
modern
method
Female
sterili-
zation
Male
sterili-
zation Pill IUD
Inject-
ables Implants Condom
Foam/
jelly
Any
tradi-
tional
method
Periodic
absti-
nence
With-
drawal
Folk
method
Not
currently
using Total
Number
of
women/
men

15-19 12.0 9.3 0.0 0.0 1.0 0.1 3.7 0.0 4.4 0.0 2.7 0.2 2.5 0.0 88.0 100.0 930
20-24 23.4 20.7 4.1 1.8 1.7 0.4 8.0 0.7 4.0 0.1 2.7 1.0 1.6 0.1 76.6 100.0 1,643
25-29 40.1 35.5 14.4 4.8 1.6 0.7 9.4 1.1 3.5 0.0 4.6 1.1 3.4 0.1 59.9 100.0 1,625
30-34 53.5 48.0 19.3 9.6 2.7 0.7 12.3 0.7 2.7 0.1 5.4 1.5 3.5 0.4 46.5 100.0 1,377
35-39 56.2 51.8 25.5 9.2 2.2 0.4 11.6 0.7 2.2 0.1 4.4 1.5 2.4 0.4 43.8 100.0 1,099
40-44 51.9 47.8 26.7 10.7 1.1 0.1 7.3 0.6 1.3 0.0 4.1 1.6 2.0 0.5 48.1 100.0 936
45-49 40.0 36.9 21.1 12.1 0.1 0.1 2.9 0.2 0.4 0.0 3.1 0.7 1.9 0.5 60.0 100.0 732

Total:
women

39.3

35.4

15.0

6.3

1.6

0.4

8.4

0.6

2.9

0.0

3.9

1.1

2.6

0.3

60.7

100.0

8,342


Total: men 48.7 43.6 17.1 6.8 1.9 0.4 10.2 0.7 6.3 0.1 5.1 2.0 2.8 0.3 51.3 100.0 2,198
Note: If more than one method is used, only the most effective method is considered in this tabulation.
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The 2001 NDHS indicates that 39 percent of currently married women are using a method of
family planing. The 35 percent who are using modern contraceptives represents a dramatic increase
in the use of modern methods from 26 percent in the 1996 NFHS (Pradhan et al., 1997).

The increase in the use of modern contraceptive methods is mainly due to a significant rise in
use of injectables and female sterilization. The use of injectables has increased in the last five years
from 5 percent in 1996 to 8 percent in 2001, while the percentage of currently married women who
have been sterilized grew from 12 percent to 15 percent. Use of other modern methods has changed
little in the last five years. Six percent of currently married women are using male sterilization,
3 percent are using condoms, 2 percent are using the pill, and less than 1 percent each are using the
IUD, implants, and foam or jelly.Contraceptive use varies by age. Typically, an inverted U-shaped
pattern of prevalence by age is observed. Use is lower among younger women (because they are in
the early stage of family building) and among older women (some of whom are no longer fecund)
than among those at intermediate ages. For example, current use of a modern contraceptive method
is 9 percent for married women age 15-19, rises to 52 percent among women age 35-39, and then
drops sharply to 37 percent at age 45-49. Most of the women who are sterilized are over age 35,
while injectables are popular among women age 25-39.

Overall, the data show that married men are consistently more likely than married women to
report that they are currently using a family planning method. Among currently married men,
49 percent report use of a method, with 44 percent using a modern method. The largest difference in
current use by gender is in the reported use of condoms. Men are twice as likely to report use of
condoms as women (6 percent compared with 3 percent, respectively). Such a large discrepancy may
be due to several reasons: the higher reported use of condoms by married men may be due to use
with women other than their wife, men may be overreporting due to insufficient knowledge of
female methods like injectables or because they are embarrassed to admit that they are not practicing
family planning, women may be underreporting because they are too shy to report use or for fear of
reprisal from other family members. Although there is no clear basis to suspect the information given
either by women or men as unreliable, since the majority of methods are female methods, womens
reports may be closer to actual use.

5.4 CURRENT USE OF CONTRACEPTION BY BACKGROUND CHARACTERISTICS

The study of differentials in current use of contraception is important because it helps identify
subgroups of the population to target for family planning services. Tables 5.4.1 and 5.4.2 present
the percent distribution of currently married women and men by their current use of family planning
methods, according to background characteristics. These tables allow the comparison of levels of
current contraceptive use among major groups of the population. They also permit an examination of
differences in the method mix among current users within the various subgroups.

There are substantial differences in the use of contraceptive methods among sub-groups of
currently married women and men. Women in urban areas are more likely to use a family planning
method than their rural counterparts, reflecting wider availability and easier access to methods in
urban areas than in rural areas, as well as the fact that urban women are more likely to be educated
than rural women. The contraceptive prevalence rate for any method is 62 percent in urban areas,
compared with 37 percent in rural areas. The difference is largely due to more women in the urban
areas using modern contraception (56 percent) than in the rural areas (33 percent). Urban-rural
differentials in use among married men are less pronounced than among married women.

72 * Family Planning

Table 5.4.1 Current use of contraception by background characteristics: women


Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Nepal 2001


Modern method

Traditional method


Background
characteristic
Any
method
Any
modern
method
Female
sterili-
zation
Male
sterili-
zation Pill IUD
Inject-
ables Implants Condom
Foam/
jelly
Any
traditional
method
Periodic
absti-
nence
With-
drawal
Folk
method
Not
currently
using Total
Number
of
women

Residence


Urban 62.2 56.3 21.8 7.6 3.5 1.6 13.8 2.8 5.1 0.1 5.9 2.4 3.3 0.2 37.8 100.0 792

Rural 36.9 33.2 14.3 6.2 1.4 0.3 7.9 0.4 2.7 0.0 3.7 1.0 2.5 0.3 63.1 100.0 7,550

Ecological zone
Mountain 31.8 27.3 2.3 8.8 2.1 0.5 11.3 0.4 1.7 0.1 4.5 1.5 2.9 0.1 68.2 100.0 573
Hill 36.6 32.7 7.1 9.1 2.0 0.5 9.8 1.1 3.0 0.0 3.9 0.7 3.0 0.2 63.4 100.0 3,444
Terai 42.5 38.6 23.0 3.8 1.2 0.3 7.0 0.3 2.9 0.0 3.9 1.4 2.2 0.3 57.5 100.0 4,325

Development region
Eastern 45.8 37.9 17.1 4.2 2.8 0.2 9.8 0.6 3.1 0.0 7.9 3.1 4.6 0.2 54.2 100.0 2,002
Central 40.2 36.9 15.9 6.2 1.5 0.7 8.6 1.3 2.5 0.1 3.3 0.6 2.2 0.5 59.8 100.0 2,684
Western 36.9 34.3 12.3 9.5 1.2 0.4 7.8 0.2 2.9 0.1 2.7 0.8 1.8 0.0 63.1 100.0 1,693
Mid-western 35.7 33.8 14.4 7.3 0.8 0.1 8.3 0.1 2.9 0.0 1.9 0.1 1.7 0.1 64.3 100.0 1,150
Far-western 30.7 28.8 13.3 4.1 1.3 0.2 6.3 0.0 3.6 0.0 1.9 0.2 1.5 0.1 69.3 100.0 813

Subregion
Eastern Mountain 45.2 38.7 2.3 13.9 1.9 0.3 14.5 0.3 4.8 0.6 6.5 3.2 3.2 0.0 54.8 100.0 118
Central Mountain 41.8 35.9 3.8 10.7 3.2 1.1 14.2 1.1 1.9 0.0 5.9 1.9 4.0 0.0 58.2 100.0 197
Western Mountain 17.9 15.5 1.1 4.9 1.3 0.2 7.6 0.0 0.2 0.0 2.5 0.4 1.8 0.2 82.1 100.0 258
Eastern Hill 36.2 27.5 5.3 4.9 4.0 0.8 8.2 1.0 3.4 0.0 8.7 1.4 7.3 0.0 63.8 100.0 552
Central Hill 50.9 46.9 6.7 10.5 3.0 1.2 18.1 3.4 4.0 0.1 3.9 1.2 2.2 0.6 49.1 100.0 899
Western Hill 34.1 31.0 8.9 11.5 1.7 0.3 6.0 0.2 2.4 0.0 3.1 0.6 2.5 0.0 65.9 100.0 1,017
Mid-western Hill 28.7 26.9 7.7 8.6 0.3 0.0 7.8 0.0 2.5 0.0 1.9 0.0 1.9 0.0 71.3 100.0 627
Far-western Hill 21.8 20.1 4.9 6.4 0.5 0.0 5.6 0.0 2.7 0.0 1.6 0.0 1.4 0.2 78.2 100.0 349
Eastern Terai 49.8 42.1 23.3 3.1 2.3 0.0 10.0 0.5 2.9 0.0 7.7 3.8 3.6 0.3 50.2 100.0 1,332
Central Terai 33.9 31.3 22.7 3.2 0.5 0.4 2.6 0.2 1.7 0.1 2.6 0.1 1.9 0.6 66.1 100.0 1,588
Western Terai 41.2 39.3 17.3 6.4 0.4 0.6 10.5 0.3 3.6 0.1 1.9 1.1 0.8 0.0 58.8 100.0 676
Mid-western Terai 51.3 48.9 28.1 4.8 1.5 0.3 9.6 0.3 4.2 0.0 2.3 0.2 1.9 0.3 48.7 100.0 417
Far-western Terai 46.2 45.0 28.2 2.5 2.0 0.4 5.6 0.0 6.2 0.0 1.2 0.2 1.0 0.0 53.8 100.0 313

Education
No education 36.6 33.5 16.3 5.8 1.3 0.2 7.8 0.5 1.5 0.0 3.1 0.9 1.9 0.3 63.4 100.0 5,970
Primary 41.8 37.7 12.3 8.7 2.3 0.4 9.6 1.0 3.5 0.0 4.1 1.2 2.7 0.2 58.2 100.0 1,247
Some secondary 48.5 41.1 12.0 7.2 2.5 0.6 10.5 0.8 7.4 0.1 7.4 1.4 6.0 0.1 51.5 100.0 793
SLC and above 57.2 46.4 8.7 4.3 3.1 3.7 11.0 1.0 14.3 0.3 10.7 4.3 6.4 0.0 42.8 100.0 332

Number of living children
0 6.9 5.2 0.0 0.6 0.7 0.0 0.4 0.0 3.6 0.0 1.7 0.2 1.5 0.0 93.1 100.0 1,006
1-2 32.5 28.2 7.5 4.2 2.0 0.7 9.1 0.8 3.9 0.0 4.4 1.1 3.1 0.1 67.5 100.0 2,963
3-4 55.1 51.0 26.5 10.3 1.7 0.3 8.9 0.8 2.4 0.1 4.1 1.4 2.5 0.2 44.9 100.0 2,878
5+ 44.1 39.9 17.9 6.7 1.4 0.3 11.7 0.4 1.5 0.0 4.2 1.2 2.3 0.7 55.9 100.0 1,495

Total 39.3 35.4 15.0 6.3 1.6 0.4 8.4 0.6 2.9 0.0 3.9 1.1 2.6 0.3 60.7 100.0 8,342
Note: If more than one method is used, only the most effective method is considered in this tabulation.
SLC = School Leaving Certificate


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Table 5.4.2 Current use of contraception by background characteristics: men

Percent distribution of currently married men by contraceptive method currently used, according to background characteristics, Nepal 2001


Modern method

Traditional method


Background
characteristic
Any
method
Any
modern
method
Female
sterili-
zation
Male
sterili-
zation Pill IUD
Inject-
ables Implants Condom Foam/ jelly
Any
traditional
method
Periodic
absti-
nence
With-
drawal
Folk
method
Not
currently
using Total
Number
of
men

Residence


Urban 66.0 59.0 19.3 6.8 3.0 1.9 15.9 2.8 9.0 0.4 7.1 2.7 3.6 0.7 34.0 100.0 223

Rural 46.8 41.8 16.8 6.8 1.8 0.2 9.5 0.5 6.1 0.1 4.9 2.0 2.7 0.3 53.2 100.0 1,975



Ecological zone

Mountain 34.0 28.9 2.0 10.9 2.0 0.6 9.1 1.1 3.0 0.3 5.1 2.0 2.7 0.4 66.0 100.0 144

Hill 45.0 39.7 7.5 8.7 2.6 0.5 11.6 1.3 7.2 0.3 5.4 1.6 3.8 0.0 55.0 100.0 869

Terai 53.2 48.3 25.9 4.9 1.4 0.3 9.3 0.3 6.2 0.0 5.0 2.4 2.1 0.5 46.8 100.0 1,185



DEVELOPMENT REGION

Eastern 54.8 45.8 18.9 5.4 2.4 0.3 11.6 0.8 6.4 0.1 8.9 4.2 4.4 0.3 45.2 100.0 569

Central 47.9 43.5 18.0 7.5 1.1 0.8 9.9 1.2 5.0 0.1 4.4 1.4 2.4 0.6 52.1 100.0 732

Western 46.8 41.8 12.5 8.1 2.3 0.0 11.5 0.2 6.8 0.3 5.0 1.6 3.5 0.0 53.2 100.0 421

Mid-western 44.1 43.0 18.6 6.8 2.1 0.0 8.4 0.6 6.6 0.0 1.1 0.6 0.5 0.0 55.9 100.0 285

Far-western 44.8 42.0 15.9 5.3 2.6 0.7 7.2 0.3 9.9 0.0 2.8 1.2 1.2 0.3 55.2 100.0 190



Subregion

Eastern Mountain 48.8 43.9 2.4 18.3 2.4 1.2 14.6 0.0 3.7 1.2 4.9 2.4 2.4 0.0 51.2 100.0 31

Central Mountain 37.5 32.1 2.7 11.6 2.7 0.9 8.9 2.7 2.7 0.0 5.4 1.8 3.6 0.0 62.5 100.0 57

Western Mountain 22.2 17.2 1.0 6.1 1.0 0.0 6.1 0.0 3.0 0.0 5.1 2.0 2.0 1.0 77.8 100.0 56

Eastern Hill 47.0 35.3 8.8 8.4 2.8 0.7 8.4 1.4 4.9 0.0 11.6 3.5 8.1 0.0 53.0 100.0 158

Central Hill 52.4 47.8 5.7 10.0 1.8 1.2 18.6 2.7 7.5 0.3 4.7 1.7 3.0 0.0 47.6 100.0 270

Western Hill 46.1 40.3 10.1 7.8 3.9 0.0 9.5 0.4 8.0 0.6 5.8 1.2 4.7 0.0 53.9 100.0 227

Mid-western Hill 31.4 31.4 6.9 9.2 2.3 0.0 6.2 0.0 6.9 0.0 0.0 0.0 0.0 0.0 68.6 100.0 140

Far-western Hill 36.2 33.0 4.9 6.5 2.2 0.0 9.7 0.8 8.9 0.0 3.2 1.6 1.6 0.0 63.8 100.0 75

Eastern Terai 58.5 50.3 24.4 3.2 2.3 0.0 12.6 0.5 7.3 0.0 8.2 4.7 3.1 0.4 41.5 100.0 380

Central Terai 46.4 42.3 28.3 5.3 0.4 0.5 4.2 0.0 3.6 0.0 4.2 1.1 1.9 1.1 53.6 100.0 406

Western Terai 47.6 43.5 15.3 8.5 0.5 0.0 13.8 0.0 5.4 0.0 4.1 2.0 2.0 0.0 52.4 100.0 194

Mid-western Terai 64.6 62.0 35.9 3.5 1.9 0.0 12.1 1.4 7.2 0.0 2.6 1.4 1.2 0.0 35.4 100.0 121

Far-western Terai 59.0 59.0 31.0 4.9 4.1 1.6 4.3 0.0 13.2 0.0 0.0 0.0 0.0 0.0 41.0 100.0 84



Education

No education 41.1 36.8 19.0 6.0 1.6 0.0 7.2 0.6 2.4 0.0 4.3 1.8 2.5 0.0 58.9 100.0 808

Primary 46.4 42.1 15.5 6.6 1.7 0.5 11.1 1.0 5.6 0.0 4.3 1.5 2.0 0.8 53.6 100.0 660

Some secondary 53.7 48.9 16.9 6.9 2.3 0.5 12.6 1.0 8.5 0.3 4.8 1.9 2.9 0.0 46.3 100.0 445

SLC and above 68.0 57.9 15.3 9.3 3.0 1.0 12.8 0.2 16.1 0.3 10.1 4.2 5.3 0.6 32.0 100.0 284



Number of living children

0 19.5 16.3 3.4 1.6 0.8 0.4 2.6 0.0 7.5 0.0 3.3 0.9 2.4 0.0 80.5 100.0 370

1-2 49.0 43.2 13.4 4.4 2.1 0.6 13.1 0.4 9.1 0.1 5.7 3.2 2.5 0.1 51.0 100.0 775

3-4 61.7 56.7 26.6 12.1 2.1 0.2 10.6 1.3 3.5 0.2 4.9 1.5 3.0 0.4 38.3 100.0 719

5+ 52.7 46.4 20.1 6.6 2.6 0.3 11.0 0.9 4.9 0.0 6.2 1.8 3.5 0.9 47.3 100.0 334


Total 48.7 43.6 17.1 6.8 1.9 0.4 10.2 0.7 6.3 0.1 5.1 2.0 2.8 0.3 51.3 100.0 2,198
Note: If more than one method is used, only the most effective method is considered in this tabulation.
SLC = School Leaving Certificate

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74 * Family Planning
Contraceptive use varies by place of residence with much of the difference due to a
difference in the use of female and male sterilization and injectables. Use of a modern method
among currently married women is highest in the terai (39 percent), followed by the hills
(33 percent) and mountains (27 percent). Female sterilization is extremely popular in the terai where
23 percent of women are using it. On the other hand, male sterilization is more popular in both the
mountains and hillswhere 9 percent of women each reported usethan in the terai (4 percent).
Injectables are most popular among currently married women living in the mountains (11 percent).
By development region, use of modern methods among women is highest in the Eastern region
(38 percent), closely followed by the Central region (37 percent), and lowest in the Far-western
region (29 percent). Female sterilization, injectables, and male sterilization are the most popular
methods in all the development regions. The use of traditional methods is most popular in the
Eastern development region. By subregion, modern contraceptive use is highest in the Mid-western
terai (49 percent) and lowest in the Western mountain region (16 percent). Female sterilization is
especially popular in the Mid-western and Far-western terai (28 percent each). Injectables are most
commonly used in the Central hill subregion (18 percent). Male sterilization is most popular in the
Eastern mountains (14 percent) and least in the Far-western, Eastern, and Central terai subregions
(3 percent each).

Higher educational attainment is positively correlated with current use of family planning.
Use of modern methods increases from 34 percent among currently married women with no
education to 46 percent among women with SLC and above. The most popular method among
women who have completed SLC and above is condoms (14 percent), whereas the most popular
method among women who have no education is female sterilization (16 percent). In fact, female
sterilization is the most popular method among all women who have less than an SLC level of
education. In general, as womens level of education increases they are more likely to use modern
spacing methods. A similar pattern between education and use is observed for men.

There is a direct association between use of modern family planning and the number of
children women have. Only 5 percent of women with no living children use modern contraception;
the percentage increases to 51 percent among women with three to four children and falls to
40 percent among women with five or more children. For men, this relationship is similar but less
pronounced. As expected, permanent methods are popular among high-parity women. Use of
sterilization increases with the number of living children a woman has. Nevertheless, sterilization use
is lower among women with five more children than among women with three to four children.
Injectables are also popular among high-parity women. This could be due to a number of reasons:
injectables are more easily accessible since supplies are available at most depots; they work for a
relatively longer duration; they are convenient to use; their use can be kept private; and they are
relatively less complicated to adopt.

5.5 TRENDS IN CURRENT USE OF FAMILY PLANNING

The study of trends in current use of family planning is important to assessing the
achievement of family planning programs over a period of time. Table 5.5 and Figure 5.1 show the
trend in the use of modern contraceptives among currently married nonpregnant women over the last
two and a half decades. Pregnant women are excluded from the denominator to ensure comparability
with earlier surveys; therefore, the contraceptive rates for 2001 shown here differ from Tables 5.3
and 5.4.
Family Planning * 75


Table 5.5 shows that there has been an impressive increase in the use of contraception in
Nepal over the last 25 years, with the increase in current use of modern contraception among
currently married, nonpregnant women highest between 1996 and 2001 and lowest between 1991
and 1996. There was a fivefold increase between 1976 and 1986 and a twofold increase between
1986 and 1996. Over the last five years, modern contraceptive use increased by 35 percent, from
29 percent in 1996 to 39 percent in 2001. In terms of specific modern family planning methods,
the percentage of current use accounted for by female and male sterilization together has declined
over the last decade. While the share of female sterilization decreased from 50 percent of modern
methods in 1991 to 42 percent in 2001, male sterilization declined from 31 percent to 18 percent over
the same period. On the other hand, the share of temporary methods has risen from 19 percent to
40 percent over the same period. This is an indication that more women are now using contraception
to space rather than limit births. The increase in the use of injectables is fourfold between 1991 and
2001. Even though condom use is low, it increased considerably during this period. The only method
that has not increased since 1991 is male sterilization. The reasons for the plateau in male
sterilization include low acceptability, lack of proper counseling, low priority by policymakers and
managers, inadequate resource allocation, insufficient promotional activities, misinformation and
myths, low levels of participation of males in family planning, and lack of attention to quality
assurance (Pathak, 1999).

Table 5.5 Trends in current use of modern contraceptive methods
Percentage of currently married nonpregnant women who are
currently using modern contraceptive methods, Nepal 1976-2001


Method 1976
1
1981
2
1986
3
1991
4
1996
5
2001


Any modern method 2.9 7.6 15.1 24.1 28.8
a
38.9
a



Modern method
Female sterilization 0.1 2.6 6.8 12.1 13.3 16.5
Male sterilization 1.9 3.2 6.2 7.5 6.0 7.0
Pill 0.5 1.2 0.9 1.1 1.5 1.8
Injectables 0.0 0.1 0.5 2.3 5.0 9.3
Male condom 0.3 0.4 0.6 0.6 2.1 3.2
Implants na na na 0.3 0.5 0.7
IUD 0.1 0.1 0.1 0.2 0.3 0.4

Number 4,325 5,277 3,654 22,096 7,190 7,591
Note: This table excludes pregnant women from the denominator in
order to ensure comparability with earlier surveys, and as such
contraceptive use rates for 2001 differ from Table 5.3. In contrast,
contraceptive use rates in DHS surveys are calculated based on all
married women and assume that currently pregnant women are not
currently using a method.
na = Not applicable
1
Ministry of Health, 1977;
2
Risal and Shrestha, 1989;
3
Ministry of
Health, 1987;
4
Ministry of Health, 1993;
5
Pradhan et al., 1997
a
Includes users of vaginal methods




76 * Family Planning
3
8
15
24
29
39
NFS 1976 NCPS 1981 NFFS 1986 NFHS 1991 NFHS 1996 NDHS 2001
0
10
20
30
40
50
Percent currently using
Figure 5.1 Trends in Current Use of Modern Contraceptive
Methods Among Currently Married Nonpregnant
Women Age 15-49, Nepal, 1976-2001
Nepal 2001
Note: Data for 1976 to 1996 surveys are from
Pradhan et al., 1997: Figure 4.2, p. 56.



5.6 CURRENT USE OF CONTRACEPTION BY WOMENS STATUS

A womans desire and ability to manage her fertility and her choice of contraceptive methods
are in part affected by her status, self-image, and sense of empowerment. A woman who feels that
she does not have much control over basic aspects of her life may be less likely to feel she can make
and carry out decisions about her fertility. She may also feel the need to choose methods that are less
obvious or that do not depend on her husbands cooperation (see Chapter 3 for a discussion of the
indicators).

Table 5.6 shows the distribution of currently married women by contraceptive use, according
to the three womens status indicators. Use of modern methods increases as womens participation in
decisionmaking increases. For example, 16 percent of women who have no say in any of the five
specific household decisions are using a modern method, compared with 34 percent of women who
participate in one to two decisions, 46 percent of women with a say in three to four decisions, and
42 percent of women who participate in all five decisions. However, there are no significant
differences in the percentages of women using modern methods relative to their attitudes toward a
wifes ability to refuse sex with her husband. Use varies negatively with attitude toward wife
beating. Use decreases as the number of reasons to justify wife beating increases. For example,
36 percent of women who believe that a man is not justified in beating his wife for any reason at all
are using a modern method of contraception, compared with 26 percent of women who believe that a
man is justified in beating his wife for all five reasons asked about.
Family Planning * 77



Table 5.6 Current use of contraception by women's status
Percent distribution of currently married women by contraceptive method currently used, according to selected indicators of women's status, Nepal 2001
Modern method

Traditional method



Women's status
indicators
Any
method
Any
modern
method
Female
sterili-
zation
Male
sterili-
zation Pill IUD
Inject-
ables Implants Condom
Foam/
jelly
Any
traditional
method
Periodic
absti-
nence
With-
drawal
Folk
method
Not
currently
using Total
Number
of
women


Number of decisions in
which woman has final say

0 19.1 16.4 6.4 1.8 0.7 0.3 3.8 0.2 3.1 0.0 2.7 0.6 2.1 0.0 80.9 100.0 1,284
1-2 37.5 34.0 13.6 6.1 1.5 0.3 9.2 0.6 2.7 0.0 3.4 1.2 2.1 0.2 62.5 100.0 3,701
3-4 51.8 46.2 20.6 8.5 2.2 0.9 9.3 1.0 3.7 0.1 5.6 1.8 3.5 0.4 48.2 100.0 1,869
5 45.8 41.6 19.0 8.2 1.9 0.2 9.4 0.7 2.2 0.1 4.2 0.6 3.0 0.5 54.2 100.0 1,488

Number of reasons to
refuse sex with husband

0 37.7 33.7 13.5 2.3 2.2 0.0 10.6 0.0 5.0 0.0 4.0 1.3 1.3 1.3 62.3 100.0 93
1-2 37.2 35.1 19.0 1.8 0.3 0.3 9.3 1.1 3.3 0.0 2.1 1.2 0.7 0.2 62.8 100.0 251
3-4 39.4 35.4 14.9 6.5 1.7 0.4 8.4 0.6 2.9 0.1 4.0 1.1 2.6 0.2 60.6 100.0 7,998

Number of reasons wife
beating is justified

0 40.0 35.9 15.4 6.7 1.6 0.4 8.2 0.6 2.9 0.1 4.1 1.2 2.6 0.3 60.0 100.0 5,947
1-2 38.9 35.2 12.9 6.1 1.6 0.5 10.2 0.8 3.0 0.1 3.8 1.1 2.6 0.1 61.1 100.0 1,855
3-4 35.1 31.2 18.8 3.2 1.3 0.0 4.9 0.4 2.6 0.0 4.0 0.9 2.8 0.3 64.9 100.0 433
5 26.1 26.1 14.3 3.7 2.0 0.0 6.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 73.9 100.0 106

Total 39.3 35.4 15.0 6.3 1.6 0.4 8.4 0.6 2.9 0.0 3.9 1.1 2.6 0.3 60.7 100.0 8,342
Note: If more than one method is used, only the most effective method is considered in this tabulation.

F
a
m
i
l
y

P
l
a
n
n
i
n
g


*


7
7


78 * Family Planning


5.7 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION

To examine the timing of initial family planning use during the family building process, the
2001 NDHS included a question for ever-married women who had ever used contraception that
asked about the number of living children they had at first use. Table 5.7 shows this information by
age group. An important part of this table is to examine cohort changes in parity at first use of
contraception.

Looking at first use by age, younger women report first use of contraception at lower parities
than older women. Fifty-eight percent of women age 15-19 who have ever used family planning
initiate use before having any children. This is much higher than the 2 percent among women in
their thirties, suggesting a shift toward the early use of contraception and the desire to delay
childbearing among Nepalese women. This may be because young women are more likely to use
contraceptives to space births, whereas older women use them to limit births.


Table 5.7 Number of children at first use of contraception
Percent distribution of women who have ever used contraception by number of
living children at the time of first use of contraception, according to current age,
Nepal 2001


Number of living children at time of
first use of contraception

Current age 0 1 2 3 4+ Total
Number
of
women
15-19 58.4 36.3 5.3 0.0 0.0 100.0 204
20-24 18.2 52.7 21.9 6.7 0.5 100.0 703
25-29 5.4 30.2 29.6 24.1 10.7 100.0 948
30-34 2.1 20.0 24.7 25.1 28.2 100.0 951
35-39 1.9 11.3 17.0 26.4 43.4 100.0 765
40-44 0.7 7.8 14.2 20.8 56.5 100.0 639
45-49 0.6 7.1 10.5 21.8 60.1 100.0 426

Total 7.3 23.5 20.4 20.3 28.5 100.0 4,634
Note: Total includes 2 women with missing information on number of living children
at first use of contraception who are not shown separately.



5.8 KNOWLEDGE OF FERTILE PERIOD

An elementary knowledge of reproductive physiology provides a useful background for the
successful practice of coitus-associated methods such as periodic abstinence, withdrawal, condoms,
and vaginal methods. Knowledge is particularly critical for periodic abstinence (safe period or
rhythm period). As shown in Tables 5.1, 5.2, and 5.3, respectively, 35 percent of currently married
women have heard of periodic abstinence as a method of contraception, 5 percent have used it in the
past, and 1 percent is currently using the method. To effectively use periodic abstinence as a method
of contraception, knowledge of the womans fertile period is a prerequisite. All women interviewed
in the 2001 NDHS were asked about their knowledge of their fertile period. Table 5.8 shows
respondents knowledge about the time during the menstrual cycle when a woman is most likely to
get pregnant.
Family Planning * 79


Table 5.8 Knowledge of fertile period
Percent distribution of ever-married women, by knowledge of the
fertile period during the ovulatory cycle, according to current
use/nonuse of periodic abstinence, Nepal 2001


Perceived fertile period
Users of
periodic
abstinence
Nonusers of
periodic
abstinence
All
ever-
married
women
Just before period begins 2.2 2.1 2.1
During period 1.2 1.7 1.6
Right after period has ended 60.7 40.0 40.2
Halfway between two periods 33.3 17.9 18.1
Other 0.0 0.1 0.1
No specific time 2.6 5.9 5.9
Don't know 0.0 32.4 32.0

Total 100.0 100.0 100.0
Number of women 94 8,632 8,726


Overall, only 18 percent of women correctly reported the most fertile period as being halfway
between two menstrual periods. Among users of periodic abstinence, one-third were able to correctly
identify when during a womans cycle she is most likely to get pregnant. It should be noted that one-
third of nonusers did not know about the fertile period, and two in five women stated that a woman is
most susceptible to pregnancy just after her period ends, indicating that there is still much scope for
educating women about their physiology.

5.9 STERILIZATION
TIMING OF FEMALE STERILIZATION

In countries where sterilization is prevalent, there is interest in knowing the trend in the
adoption of the method and in determining whether the age at the time of sterilization is declining.
To minimize the problem of censoring, the median age at the time of sterilization is presented only
for women sterilized at less than 40 years of age.

As mentioned earlier, 15 percent of currently married women age 15-49 reported that they
had been sterilized. Table 5.9 shows the distribution of sterilized women by the age at sterilization,
according to the number of years since the operation. The results indicate that most women
(68 percent) were sterilized before age 30, with one-fourth sterilized before age 25. This shows that
female sterilization in Nepal occurs early in womens reproductive lives. The median age at
sterilization (for women sterilized before age 40) is 28 years, which has remained roughly constant
over the last ten years.

80 * Family Planning

Table 5.9 Timing of female sterilization
Percent distribution of sterilized women by age at the time of sterilization, and
median age at sterilization, according to the number of years since the operation,
Nepal 2001


Age at time of sterilization



Years since
operation <25 25-29 30-34 35-39 40-44 Total
Number
of
women
Median
age
1

<2 26.3 44.6 18.4 9.8 0.9 100.0 194 27.7
2-3 26.6 40.9 22.7 6.9 2.9 100.0 186 27.4
4-5 31.7 33.7 20.2 12.7 1.7 100.0 163 27.7
6-7 24.4 35.7 25.5 12.6 1.8 100.0 155 28.1
8-9 23.4 45.2 21.7 8.5 1.1 100.0 113 28.2
10+ 20.9 48.2 26.2 4.7 0.0 100.0 440 a

Total 24.6 42.9 23.2 8.2 1.1 100.0 1,252 27.8

1
Median ages are calculated only for women sterilized at less than 40 years of age to
avoid problems of censoring.
a
Not calculated due to censoring


STERILIZATION REGRET

Although some level of regret is expected to occur with any permanent method of
contraception, a high level could be viewed as an indication of poor quality of care. In the 2001
NDHS, women who had been sterilized or who said their husband had been sterilized were asked
whether they regretted having had the operation and, if so, why. Table 5.10 shows sterilization regret
for women. Although similar information was obtained for men, due to the small numbers who
regretted the operation, the results are not statistically meaningful to warrant a separate analysis.

Overall, 8 percent of women who were sterilized or whose husband was sterilized reported
that they regretted the operation. About one-half of these women (4 percent) stated that they
regretted sterilization because of side effects, 2 percent of women stated that they wanted another
child, and 1 percent of women regretted sterilization because of the death of a child.

There is little variation in sterilization regret by urban-rural residence. However, women
residing in the hills and terai were much more likely to regret sterilization than women residing in
the mountains. Similarly, sterilization regret is higher among women residing in the Western
development region and the Western hill subregion. Sterilization regret is also higher among women
with one to two children.
Family Planning * 81

Table 5.10 Sterilization regret
Percentage of currently married women who are sterilized or whose husbands are sterilized who regret the operation, by reason
for regret and background characteristics, Nepal 2001


Reason for regret


Background
characteristic
Percentage
who regret
sterilization
Respondent
wants
another
child
Husband
wants
another
child
Side
effects
Marital
status has
changed
Opera-
tion
failed
Child
died Other
Number
of
women
Residence

Urban 7.7 1.9 0.0 2.5 0.6 0.4 1.7 0.2 232
Rural 7.9 1.9 0.1 4.5 0.1 0.3 0.9 0.1 1,548

Ecological zone
Mountain 2.9 1.4 0.0 0.0 1.4 0.0 0.0 0.0 63
Hill 8.2 2.7 0.2 4.0 0.0 0.2 1.1 0.0 559
Terai 8.0 1.5 0.0 4.7 0.1 0.4 1.0 0.2 1,158

Development region
Eastern 7.4 1.2 0.0 4.2 0.3 0.0 1.4 0.3 428
Central 6.9 1.5 0.0 4.2 0.1 0.3 0.9 0.0 594
Western 11.7 3.1 0.4 6.7 0.2 0.2 1.1 0.0 368
Mid-western 5.8 2.0 0.0 2.3 0.0 0.3 0.7 0.2 249
Far-western 7.3 2.0 0.0 2.2 0.0 1.8 0.5 0.7 142

Subregion
Eastern Mountain 4.0 2.0 0.0 0.0 2.0 0.0 0.0 0.0 19
Central Mountain 3.7 1.9 0.0 0.0 1.9 0.0 0.0 0.0 29
Western Mountain 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16
Eastern Hill 2.0 0.0 0.0 2.0 0.0 0.0 0.0 0.0 56
Central Hill 3.5 1.6 0.0 1.4 0.0 0.0 0.5 0.0 154
Western Hill 15.3 4.2 0.6 8.4 0.0 0.4 1.7 0.0 207
Mid-western Hill 4.9 1.6 0.0 1.6 0.0 0.0 1.6 0.0 102
Far-western Hill 6.9 5.8 0.0 0.0 0.0 0.0 1.1 0.0 40
Eastern Terai 8.4 1.4 0.0 4.8 0.2 0.0 1.6 0.4 353
Central Terai 8.5 1.5 0.0 5.5 0.0 0.4 1.1 0.0 411
Western Terai 6.9 1.7 0.0 4.4 0.4 0.0 0.4 0.0 160
Mid-western Terai 6.9 2.4 0.0 3.0 0.0 0.6 0.0 0.4 137
Far-western Terai 7.9 0.5 0.0 3.2 0.0 2.7 0.4 1.1 96

Education
No education 7.9 1.8 0.1 4.6 0.1 0.2 1.0 0.1 1,323
Primary 7.9 1.8 0.0 3.0 0.3 1.0 1.1 0.7 261
Some secondary 5.5 1.7 0.0 2.6 0.3 0.0 0.5 0.0 152
SLC and above (14.7) (5.0) (0.0) (7.8) (0.0) (0.0) (1.9) (0.0) 43

Number of living
children

0 * * * * * * * * 6
1-2 12.6 5.8 0.0 2.8 0.2 0.0 3.7 0.0 346
3-4 5.8 0.9 0.0 4.1 0.1 0.2 0.3 0.1 1,060
5+ 8.8 0.3 0.4 6.3 0.0 0.9 0.4 0.5 368

Total 7.9 1.9 0.1 4.3 0.1 0.3 1.0 0.2 1,780
Note: Total includes 2 women with missing information on reason for regret who are not shown separately. Figures in parentheses
are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been
suppressed.
SLC = School Leaving Certificate



82 * Family Planning


5.10 CONDOM USE

In the 2001 NDHS, detailed information on use of condoms was collected from men who had
ever used condoms and men who were currently using condoms. Among men who have ever used
condoms, only 2 percent first used condoms before age 16 and 8 percent first used condoms at age
16-17. This proportion continues to increase with age to 14 percent using condoms for the first time
at age 18-21, 19 percent using at age 22-24, and 21 percent using at age 25-29. First use of condoms
among ever-users is lower at older ages (above 29 years) than at younger ages (25-29). Only
3 percent of ever-users have first used condoms at age 40 and above (data not shown). Most men
(94 percent) used condoms for the first time to avoid pregnancy. Six percent of men used condoms
for the first time to avoid getting sexually transmitted diseases, 5 percent used them to avoid getting
HIV/AIDS, and 4 percent used condoms because their partner insisted. Most men who use condoms
currently report use of condoms only sometimes during their partners fertile days.

5.11 MENS ATTITUDES TOWARD CONTRACEPTION

The 2001 NDHS included several questions in the male survey to elicit information on mens
attitudes toward contraception in general and toward specific methods used commonly in Nepal. This
information is useful in formulating family planning programs and policies since men play a key role
in womens reproductive health. Mens attitudes toward family planning and specific methods are
also important in formulating educational activities geared toward addressing some of their
misconceptions and fears.

To get a sense of their attitudes toward contraception in general, men were asked for their
opinion on a number of questions pertaining to contraception and its use. The results are shown in
Table 5.11. It is encouraging to note that most ever-married Nepali men disagree that contraception
is a womans business alone (92 percent) or that a woman should be the one to get sterilized since
she is the one who gets pregnant (87 percent). More than 70 percent of men also disagree that a
woman has no right to tell a man to use a condom or that women who are sterilized may become
promiscuous. When asked specific questions about condom use, most men are knowledgeable about
their use. Seventy-four percent disagree that a condom can be reused, and 81 percent believe that a
condom protects against disease. At the same time, 69 percent of men agree that being sterilized for
a man is the same as being castrated, which could be indicative of why male sterilization is not a
more popular method of contraception in Nepal. Two in five men also believe that condoms reduce
a mans pleasure and that a condom is very inconvenient to use.
Family Planning * 83

Table 5.11 Mens attitudes toward contraception and gender roles
Percent distribution of men by whether they agree or disagree with various
statements about contraception and gender roles, Nepal 2001


Statement Agree Disagree
Don't
know/
missing Total


Condoms reduce man's pleasure 43.6 18.7 37.6 100.0

A condom is very inconvenient to use 39.6 31.4 29.0 100.0
A condom can be re-used 3.5 73.8 22.7 100.0
A condom protects against disease 80.8 4.2 15.0 100.0
A woman has no right to tell a
man to use a condom 9.7 74.7 15.6 100.0

Contraception is women's business
and a man should not have to worry
about it 6.4 91.7 1.9 100.0

Women who are sterilized may
become promiscuous 22.6 71.5 5.9 100.0

Being sterilized for a man is the same
as castration 68.6 26.8 4.5 100.0

A woman is the one who gets pregnant,
so she should be the one to get sterilized
8.9 87.4 3.8 100.0



Men were also asked detailed questions on specific methods popular in Nepal. Table 5.12
shows the percentage of men who have heard of injectables who believe that injectables are or are
not a good method of family planning and the reasons for their belief, by whether they have used or
not used the method. Two in three men who have heard of injectables believe that it is a good
method of family planning. Three-fifths of men who have used injectables believe that they are a
good method of family planning compared with two-thirds of men who have not used injectables.
The major reasons cited in favor of the method are that it is a temporary method, that it can be
stopped when children are desired, that it is effective, and that it lasts for several months. Other
reasons are that it is simple to use and it has no/few side effects. Among the 27 percent of men who
do not think injectables are a good method, more than three-quarters believe that they may harm
womens health, while one-quarter believe that they stop the menstrual flow. The pattern of
response among users and nonusers is somewhat similar.


84 * Family Planning

Table 5.12 Men's attitudes toward injectables
Percentage of men who know of injectables who believe that injectables
are or are not a good method of family planning, by whether they have
used or not used the method and the reasons for this belief, Nepal 2001


Reason
Has
used
injectables
Has not
used
injectables Total


Percentage who believe injectables
are a good family planning method 60.1 66.8 65.3

Percentage who believe injectables
are not a good family planning
method 39.5 23.2 27.0
Don't know/Missing 0.4 9.9 7.7

Total 100.0 100.0 100.0
Number of men 493 1,626 2,119

Reasons men believe that injectables are
a good family planning method

Simple to use 26.2 14.1 16.7
Effective 53.2 47.8 48.9
Affordable 7.9 11.3 10.6
No/few side effects 20.6 13.1 14.7
Can stop when children desired 65.8 59.8 61.1
Lasts for several months 35.8 31.8 32.6
Other 0.5 0.4 0.4
Don't know 0.7 0.2 0.3

Number of men 296 1,087 1,383

Reasons men believe that injectables are
not a good family planning method

Too expensive 0.0 0.3 0.2
Against religion 0.0 2.0 1.3
May harm women's health 82.0 76.8 78.5
Increases promiscuity 0.7 2.5 1.9
Can cause sterility 0.3 6.1 4.2
Method can fail 8.7 6.4 7.2
No menstruation 38.7 21.6 27.4
Involves doctor/medical personnel 4.2 6.6 5.7
Other 16.3 8.8 11.3
Don't know 0.0 0.6 0.4

Number of men 178 348 526


Table 5.13 shows the percentage of men who have heard of female sterilization who believe
that female sterilization is or is not a good method of family planning, by reasons for this belief and
whether or not they have used the method. More than three-quarters of men who have heard of
female sterilization believe that it is a good method of family planning. Most men (87 percent) who
have heard of female sterilization believe that it is a good method specifically because there is no
risk of getting pregnant again. One in two men also believe that it is a good method because it is
generally effective, while one-fifth of men believe that it is a good method because it has no/few side
effects, with users slightly more likely than nonusers to cite these two advantages of the method.
Most men believe that female sterilization is not a good method of family planning because it is
harmful to womens health (70 percent). Two-fifths of men also believe that it is not a good method
because it can lead to medical complications (with users somewhat more likely to cite this
disadvantage than nonusers), while one-fifth of men do not like the method because it is irreversible.
Users are also twice as likely as nonusers to say that female sterilization is not a good method of
family planning because it involves a doctor and medical personnel (8 percent and 4 percent,
respectively).
Family Planning * 85

Table 5.13 Men's attitudes toward female sterilization
Percentage of men who know of female sterilization who believe that female
sterilization is or is not a good method of family planning, by whether they have
used or not used the method and reasons for this belief, Nepal 2001


Reason
Has used
female
sterilization
Has not used
female
sterilization Total

Percent who believe sterilization is
a good family planning method 71.7 79.1 77.5

Percent who believe sterilization is
not a good family planning method 26.8 19.1 20.8
Don't know/Missing 1.5 1.8 1.7

Total 100.0 100.0 100.0
Number of men 491 1,734 2,225

Reasons men believe female sterilization is
a good family planning method

Effective 57.5 47.6 49.6
Affordable 5.8 3.2 3.8
No/few side effects 24.2 18.8 19.9
No risk of getting pregnant 84.5 87.9 87.2
Other 1.3 0.7 0.8
Don't know 0.7 0.2 0.3

Number of men 352 1,372 1,724


Reasons men believe female sterilization is
not a good family planning method

Too expensive 0.0 1.0 0.8
Against religion 5.1 9.0 8.0
May harm women's health 64.8 72.1 70.2
Increases promiscuity 1.5 6.0 4.8
Cannot have children again 19.0 18.5 18.6
Method can fail 9.2 6.5 7.2
Involves doctor/medical personnel 8.0 3.9 4.9
Can lead to medical complications 47.5 39.7 41.8
Other 9.0 2.3 4.1
Don't know 0.0 0.3 0.2

Number of men 115 319 434


5.12 SOURCE OF CONTRACEPTION

Table 5.14 on source of contraception is intended simply to document the main sources of
contraception for users of different contraceptive methods. Such information on where women obtain
their contraceptive method is important for family planning program managers and implementers.
All current users of modern contraceptive methods were asked the most recent source of their
methods. The public sector remains the major source of contraceptive methods in Nepal, providing
methods to four in five current users. The share of the public sector has remained constant over the
last five years. Eight percent of users get their methods from the nongovernment sector, mostly from
the Family Planning Association of Nepal (FPAN), and 7 percent get their methods from the private
medical sector, mostly from pharmacies.

86 * Family Planning






Table 5.14 Source of contraception
Percent distribution of current users of modern contraceptive methods by most recent source of method, according to
specific method, Nepal 2001


Source
Female
sterili-
zation
Male
sterili-
zation Pill IUD
Inject-
ables Implants Condom Total

Government sector 85.8 81.0 55.3 (64.3) 86.0 51.5 46.0 79.4
Government hospital, clinic 41.9 27.6 9.6 (45.6) 7.8 37.7 4.7 26.6
PHC/Health center 3.0 2.4 3.4 (14.7) 9.2 8.0 2.9 4.6
Health post 0.0 0.0 7.3 (0.0) 15.6 1.6 8.0 4.7
Sub-health post 0.0 0.0 23.2 (0.0) 48.6 2.0 21.3 14.4
PHC outreach clinic 0.0 0.0 0.0 (0.0) 2.6 2.3 0.0 0.7
FCHV 0.0 0.0 11.7 (0.0) 1.9 0.0 9.2 1.7
Mobile camp 40.8 50.7 0.0 (0.0) 0.0 0.0 0.0 26.4
Other 0.2 0.3 0.0 (4.0) 0.3 0.0 0.0 0.2

Non-gov't (NGO) sector 6.8 11.2 7.6 (11.0) 5.1 42.3 4.2 7.7
FPAN 4.8 7.2 4.8 (8.5) 4.2 8.6 1.8 4.9
Marie Stopes 0.7 0.3 0.0 (2.5) 0.2 3.4 0.0 0.5
ADRA 0.2 0.6 0.0 (0.0) 0.4 27.2 0.0 0.8
Nepal Red Cross 0.0 0.0 1.6 (0.0) 0.0 0.0 1.1 0.2
Other 1.1 3.0 1.1 (0.0) 0.4 3.1 1.3 1.3

Private medical sector 1.1 0.6 30.1 (18.5) 7.7 6.2 38.1 7.3
Private hospital/clinic/
nursing home

1.1

0.6

3.1

(18.5)

2.6

4.6

0.3

1.6

Pharmacy 0.0 0.0 27.0 (0.0) 5.1 1.5 37.8 5.7

Other source 0.0 0.0 2.6 (0.0) 0.4 0.0 8.3 0.9
Shop 0.0 0.0 1.6 (0.0) 0.0 0.0 4.9 0.5
Friend, relative 0.0 0.0 1.0 (0.0) 0.4 0.0 3.4 0.4

Other 6.2 2.9 4.5 (4.5) 0.8 0.0 3.4 3.9

Don't know 0.0 4.4 0.0 (0.0) 0.0 0.0 0.0 0.8

Missing 0.0 0.0 0.0 (1.6) 0.0 0.0 0.0 0.0

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number of women 1,252 528 135 34 705 54 241 2,952
Note: Total includes 3 users of foam/jelly who are not shown separately. Figures in parentheses are based on 25-49
unweighted cases.
PHC = Primary health center
FCHV = Female community health volunteer
FPAN = Family Planning Association of Nepal
ADRA = Adventist Development Relief Agency


Family Planning * 87



In the public sector, 27 percent of the users obtained their contraceptive methods from
government hospitals or clinics, 14 percent from government sub-health posts, and 26 percent from
mobile camps. In the private medical sector, the pharmacy is the most commonly used source,
providing contraceptive methods to 6 percent of all users of modern methods. Most contraceptives
sold in pharmacies are provided through the Nepal Contraceptive Retail Sales Company.

Female and male sterilizations were conducted mostly in government hospitals (42 and
28 percent, respectively) and mobile camps (41 and 51 percent, respectively). One in two users of
injectables obtained their supply from government sub-health posts and 16 percent got them from
government health posts. Pills are obtained primarily from pharmacies (27 percent), government sub-
health posts (23 percent), female community health volunteers (FCHVs) (12 percent), and
government hospitals or clinics (10 percent). Condoms are obtained primarily from pharmacies
(38 percent), government sub-health posts (21 percent), and FCHVs (9 percent). These findings point
to the huge reliance on government facilities for the supply of contraceptives.

5.13 TIME TAKEN TO REACH SOURCE OF CONTRACEPTION

One of the important indicators of accessibility of contraceptives is the travel time to get to
the source of contraceptives. Studies have shown that improvement in accessibility can have a
positive effect on contraceptive prevalence.

In the 2001 NDHS, women who were currently using a method were asked to estimate the
time taken to reach the place they last obtained contraceptives. Table 5.15 shows the time taken to
reach the source by users of the pill, injectables, and condoms by place of residence, ecological zone,
and region.


Table 5.15 Time taken to reach source of contraception
Median time (in minutes) taken by currently married women to reach
source of modern contraceptive methods the last time they obtained a
modern method, by background characteristics, Nepal 2001


Method

Background
characteristic Pill
Inject-
ables Condom Total

Residence

Urban (15.6) 15.9 15.7 15.8
Rural 30.1 30.5 30.3 30.4

Ecological zone
Mountain * 30.6 * 30.6
Hill 20.9 30.4 30.5 30.4
Terai 20.3 30.1 20.5 30.0

Development region
Eastern 20.4 30.3 30.0 30.1
Central (30.0) 20.6 15.9 20.6
Western * 30.4 (30.1) 30.4
Mid-western * 60.3 (60.1) 60.2
Far-western * 30.2 20.7 30.1

Total 21.0 30.3 30.1 30.2
Note: Figures in parentheses are based on 25-49 unweighted cases. An
asterisk indicates that a figure is based on fewer than 25 unweighted
cases and has been suppressed.




88 * Family Planning



In general, it takes half an hour for users of these three methods to access a source. Pill users
are closest to their source with a median of 21 minutes, compared with injectable and condom users,
who generally take 30 minutes to reach their source. This is an indication that some of the most
popular modern methods (pills, injectables, condoms) are found locally, which could be attributed to
the expansion of health institutions (primary health centers, health posts, and sub-health posts)
throughout the kingdom, as well as the increased prevalence of FCHVs who are depot holders for
pills and condoms in many communities.

As expected, urban users are generally closer to their source of contraceptives than rural
users, with rural users taking twice as long as urban users to reach a source for any of the three
methods (30 minutes and 15 minutes, respectively). There is little difference in time to a source by
ecological zone. Time to a contraceptive source is shortest in the Central development region (21
minutes), with condoms just 16 minutes away.

5.14 INFORMED CHOICE

Informed choice is an important tool for monitoring the quality of family planning services.
All providers of sterilization must inform potential users that the operation is a permanent,
irreversible method; potential users must also be informed of other methods that could be used.
Family planning providers should also inform all method users of potential side effects and what
they should do if they encounter signs of a problem. This information assists users in coping with
side effects and decreases unnecessary discontinuation of temporary methods. Users of temporary
methods should also be informed of the choices they have with respect to other methods.

Table 5.16 presents information on informed choice by type of method, type of provider,
place of residence, and level of education. The data show that less than two-fifths (38 percent) of
current users were informed about possible side effects or problems of the method used, only one in
three were informed what to do if they experienced side effects, and less than three in ten women
were informed of other methods that could be used. However, three-fourths of female sterilization
users were informed that sterilization is permanent.

Among the three main sectors providing methods (government, nongovernment, and private
medical sectors), the private medical sector (private hospital, clinic, or pharmacy) appears to be the
most sensitive to client needs. Two-thirds of women who obtained their method for the first time
from the private medical sector were informed about side effects or problems of the method used,
56 percent were informed about what to do if they experienced side effects, and one in two were
informed of other methods that could be used. The government sector, on the other hand, is the least
responsive to client needs, with only about one in three users being adequately informed.

Surprisingly, there is little urban-rural difference or difference by development region in
informed choice, indicating that there is much scope for improving the quality of family planning
services throughout the country. Informed choice is lowest in the terai and highest in the mountains.
Informed choice is also lowest in the Central terai subregion. As expected, women with at least an
SLC are better informed than women with little or no education.
Family Planning * 89

Table 5.16 Informed choice

Among current users of modern contraceptive methods who adopted their current method in the five years preceding the
survey, percentage who were informed about the side effects of the method, percentage who were informed what to do if side
effects were experienced, and percentage who were informed of other methods that could be used for contraception, and
percentage of women who were sterilized in the five years preceding the survey who were informed that they would not be able
to have any more children, by specific method, initial source of method, and background characteristics, Nepal 2001


Method/source/
background characteristic
Informed about
side effects
or problems of
method used
Informed what
to do if
experienced
side effects
Informed by a health
or family planning
worker of other
methods that
could be used
1

Informed that
sterilization is
permanent
2


Method

Female sterilization 19.1 17.2 12.3 74.8
Pill 50.8 48.4 52.6 na
IUD 67.7 64.4 61.2 na
Injectables 62.6 55.8 48.3 na
Implants 85.0 82.7 68.9 na

Initial source of method
3

Government sector 37.7 34.0 28.3 74.7
Government hospital, clinic 27.7 23.5 23.3 76.1
PHC center/Health center 53.1 47.1 47.7 83.8
Health post 69.4 59.3 55.1 na
Sub-health post 64.3 59.8 47.9 na
PHC outreach clinic 53.1 45.7 56.8 na
FCHV 66.4 54.9 50.1 na
Mobile camp 20.0 19.8 9.2 72.5
Other public 69.9 69.9 48.7 100.0
Non-gov't (NGO) sector 44.8 44.6 39.7 74.1
FPAN 40.5 36.9 37.0 76.2
Marie Stopes 62.4 79.5 30.3 64.4
ADRA 88.6 88.6 75.0 100.0
Nepal Red Cross 27.4 27.4 27.4 na
Other NGO 22.6 28.3 30.1 65.4
Private medical sector 65.8 55.8 49.6 82.0
Private hospital, clinic 65.2 59.4 54.1 82.0
Pharmacy 67.0 54.1 46.1 na
Other 18.8 17.9 13.1 76.5

Residence
Urban 40.1 38.2 33.5 77.7
Rural 37.0 33.2 27.6 74.4

Ecological zone
Mountain 59.2 51.7 40.1 78.6
Hill 47.8 44.6 39.1 80.1
Terai 30.7 27.3 22.3 73.5

Development region
Eastern 37.6 32.3 27.4 76.5
Central 36.2 33.0 28.8 76.8
Western 41.6 37.3 33.6 76.5
Mid-western 36.0 39.3 24.9 67.4
Far-western 36.5 28.6 25.9 69.5

Subregion
Eastern Mountain 50.0 38.3 14.5 57.1
Central Mountain 66.7 64.4 56.3 85.7
Western Mountain 54.3 41.3 34.8 80.0
Eastern Hill 56.1 52.9 42.6 86.1
Central Hill 51.1 48.3 45.8 87.5
Western Hill 41.5 35.2 34.2 80.3
Mid-western Hill 44.6 47.0 28.4 72.2
Far-western Hill 36.1 29.5 27.9 65.9
Eastern Terai 32.9 27.4 24.7 75.8
Central Terai 22.4 19.0 14.0 74.9
Western Terai 41.8 39.2 33.1 73.6
Mid-western Terai 29.6 33.6 22.5 65.5
Far-western Terai 34.3 27.6 23.6 69.9

Education
No education 34.0 30.8 25.1 74.2
Primary 43.0 37.1 36.2 80.2
Some secondary 47.0 45.0 38.3 71.1
SLC and above 55.2 52.6 37.9 80.7

Total 37.5 34.0 28.5 74.8
PHC = Primary Health Care; FCHV = Female community health volunteer; FPAN = Family Planning Association of
Nepal; ADRA = Adventist Development Relief Agency
na = Not applicable
SLC = School Leaving Certificate
1
Includes users of foam/jelly who are not shown separately
2
Sterilized women who were told that they would not be able to have any more children
3
Source at start of current episode of use



90 * Family Planning


5.15 FUTURE USE OF CONTRACEPTION

An important indicator of the changing demand for family planning is the extent to which
nonusers of contraception plan to use family planning in the future. Currently married women and
men who were not using contraception at the time of the survey were asked about their intention to
use family planning in the future. The results are shown in Tables 5.17. Among currently married
women who are not using contraception, 73 percent reported that they intend to adopt a family
planning method in the future, 24 percent said that they did not intend to use a method, and 3 percent
were unsure of their intention. Among currently married men who are not using contraceptives, two-
thirds reported that they intend to adopt a family planning method in the future and nearly one-third
said they did not intend to use a method. There are differences in the percentage of women and men
who intend to use family planning according to the number of living children.
1
The proportion of
women intending to use family planning peaks at 85 percent among nonusers with one child,
declines to 73 percent among women with three children, and further declines sharply to 53 percent
among women who have four or more children. Intention to use by number of living children among
currently married men follows a similar pattern. However, a sharp decline in intention to use is more
obvious among men with three or more children.


Table 5.17 Future use of contraception
Percent distribution of currently married women and men who are
not using a contraceptive method by intention to use in the future,
according to number of living children, Nepal 2001


Number of living children
1


Intention 0 1 2 3 4+ Total
WOMEN

Intends to use 83.8 85.0 82.4 72.8 53.4 73.2

Unsure 4.2 2.1 2.5 3.1 2.3 2.7
Does not intend to use 12.0 12.9 15.0 24.1 44.3 24.1
Missing 0.0 0.0 0.1 0.0 0.0 0.0

Total 100.0 100.0 100.0 100.0 100.0 100.0
Number of women 715 1,058 1,011 807 1,470 5,061
MEN

Intends to use 72.6 79.3 74.6 58.2 47.1 65.9

Does not intend to use 21.5 18.7 23.7 40.3 50.1 31.0
Missing 6.0 2.0 1.6 1.5 2.8 3.1

Total 100.0 100.0 100.0 100.0 100.0 100.0
Number of men 298 201 194 159 275 1,127

1
Includes current pregnancy

1
Some of this difference may be muted because for women, the number of living children includes current
pregnancy, but for men, it does not, since the survey did not collect information on the pregnancy status of each wife.
Family Planning * 91
5.16 REASONS FOR NONUSE OF CONTRACEPTION

An understanding of the reasons that people do not like to use family planning methods is
critical in designing programs that could improve the quality of services. Table 5.18 shows
the percent distribution of currently married women and men who are not using a contraceptive
method and who do not intend to use in the future by the main reasons for not intending to use.
Questions on reasons for nonuse were asked of currently married women only but were extended to
all ever-married men in the male survey. To compare female and male responses, the information
for men is restricted to currently married men only. Only the total is shown for men, however, since
the male sample size is insufficient to allow a breakdown by the two age groups, as done for women.


Table 5.18 Reason for not intending to use contraception
Percent distribution of currently married women and men who are not using a
contraceptive method and who do not intend to use in the future by main reason for
not intending to use, according to (for women only) age, Nepal 2001


Age of women
Reason 15-29 30-49
Percentage
of
women
Percentage
of
men
Fertility-related reasons 20.6 52.8 48.3 71.3
Infrequent sex/no sex 4.2 9.2 8.5 6.3
Menopausal/had hysterectomy
1
0.0 6.8 5.8 53.0
Subfecund/infecund
2
4.2 32.4 28.4 6.5
Wants as many children as possible 12.1 4.4 5.5 5.5

Opposition to use 43.5 11.4 15.9 11.8
Respondent opposed 0.5 0.8 0.8 1.6
Husband/partner/wife(s) opposed
3
5.1 3.1 3.3 0.1
Others opposed 1.8 0.5 0.6 0.0
Religious prohibition 36.1 7.0 11.1 10.1

Lack of knowledge 5.0 1.7 2.2 0.6
Knows no method 1.4 0.6 0.7 0.4
Knows no source 3.6 1.1 1.4 0.3

Method-related reasons 30.0 28.5 28.7 11.0
Health concerns 2.4 7.3 6.6 4.7
Fear of side effects 25.4 20.4 21.1 5.9
Lack of access/too far 0.0 0.3 0.3 0.4
Costs too much 0.9 0.3 0.3 0.0
Inconvenient to use 0.6 0.0 0.1 0.0
Interferes with body's normal processes 0.7 0.2 0.3 0.0

Other 0.0 5.4 4.6 4.2

Dont know

Missing
0.9

0.0
0.1

0.0
0.2

0.0
0.6

0.5

Total 100.0 100.0 100.0 100.0
Number 172 1,048 1,220 349

1
For men this refers to wife(s) menopausal/had hysterectomy
2
For men this refers to couple subfecund/infecund
3
For men this refers to wife(s) opposed




92 * Family Planning

Nearly one in two women does not intend to use contraception in the future because of
fertility-related reasons. Most of these women (28 percent) report themselves to be subfecund or
infecund. Sixteen percent of women do not intend to use because of opposition to use, with most of
them citing religious opposition as a reason for nonuse. Twenty-nine percent of women cited
method-related reasons for nonuse, the most important of these being fear of side effects
(21 percent). Women age 15-29 are most likely to cite opposition to use (44 percent), with religious
opposition being the primary reason (36 percent). Thirty percent of young women also mentioned
method-related reasons, primarily fear of side effects (25 percent), as a major reason for nonuse in
the future. On the other hand, more than one in two women age 30-49 cited fertility-related reasons
for nonuse in the future, with one-third of them reporting themselves as subfecund or infecund.
Twenty-nine percent of women in this age group also cited method-related reasons, primarily fear of
side effects (20 percent), as another major reason for nonuse in the future.

Seventy-one percent of men do not intend to use a method of contraception because of
fertility-related reasons, foremost among them the wife being menopausal or having had a
hysterectomy. Religious opposition is also an important reason for nonuse in the future among men
(10 percent). Method-related reasons for nonuse in the future are cited by 11 percent of men.

Overall, these data suggest that there is substantial scope for family planning programs to
increase contraceptive use by providing advocacy and high-quality services. Stepped-up information
and education activities will play an important role in dispelling fears and misconceptions about
specific methods of contraception and contraceptive use in general.

5.17 PREFERRED METHOD OF CONTRACEPTION FOR FUTURE USE

Future demand for specific methods of family planning can be assessed by asking nonusers
who intend to use in the future which methods they prefer to use. Table 5.19 provides some
indication of womens and mens preferences for the method they might use in the future. However,
the information should be interpreted with caution since two conditions are implied here: intention to

Table 5.19 Preferred method of contraception for future use
Percent distribution of currently married women and men who are not using a
contraceptive method but who intend to use in the future by preferred
method, according to age, Nepal 2001

Women Men
Method 15-29 30-49 Total 15-29 30-49 Total
Female sterilization 34.6 23.0 31.7 26.6 29.1 27.7
Male sterilization 8.6 7.8 8.4 25.8 26.1 25.9
Pill 7.3 12.0 8.5 6.3 9.2 7.6
IUD 0.9 0.7 0.8 0.7 0.8 0.8
Injectables 25.6 34.6 27.8 16.6 13.6 15.3
Implants 3.3 3.6 3.4 4.6 3.1 3.9
Condom 1.5 2.3 1.7 12.5 10.6 11.7
Foam/jelly 0.1 0.2 0.1 0.4 1.0 0.6
Periodic abstinence 0.2 0.5 0.3 0.6 1.6 1.0
Withdrawal 0.3 1.3 0.5 0.1 1.0 0.5
Other 0.1 0.3 0.2 0.0 0.0 0.0
Unsure 17.5 13.7 16.5 5.8 3.8 5.0

Total 100.0 100.0 100.0 100.0 100.0 100.0
Number of women 2,795 908 3,703 413 329 742

Family Planning * 93


use and method preferred if intention is followed. Currently married women who reported that they
intend to adopt family planning methods were asked about the contraceptive methods they intend to
use in the future. The results in Table 5.19 indicate that most women and men prefer to use female
sterilization (32 percent and 28 percent, respectively). Twice as many women as men cited
injectables as a preferred method for future use (28 percent and 15 percent, respectively). Men are
three times more likely than women to prefer male sterilization as a future method (26 percent and
8 percent, respectively). About 8 percent of women and men mentioned the pill as a future method
of preference. There has been little change in method preference over the last five years. Data from
the 1996 NFHS show that 27 percent of currently married women intend to use female sterilization
in the future and 28 percent intend to use injectables.

5.18 EXPOSURE TO FAMILY PLANNING MESSAGES

The electronic media, such as radio and television, are important for communicating
messages about family planning. Information on the level of exposure to such media is important for
program managers and planners to effectively target population s for information, education, and
communication (IEC) campaigns. In Nepal, the most common media source is radio. Television is
mostly found in urban areas, while print media is mostly accessed by the educated. To assess the
extent to which media serves as a source of family planning messages, respondents were asked
whether they had heard or seen a message about family planning on the radio or television or in print
media in the few months preceding the survey. The results are shown in Table 5.20.

The majority of women (55 percent) and men (66 percent) have heard a family planning
message recently on the radio. Only 22 percent and 32 percent of women and men, respectively,
heard family planning messages on television. Ten percent of women and 25 percent of men read
about family planning in the print media (newspaper/magazine). Two-fifths of women and more
than one-fourth of men had not been exposed to family planning messages in any media source.

There is little difference in womens exposure to media messages on family planning by age;
nevertheless, older women (age 45-49) are least likely to have been exposed to family planning
messages in any media. On the other hand, exposure to media messages varies by age among men.
Younger men (below age 40) are more likely to have been exposed to media messages on family
planning than older men.

Urban women and men are much more likely to have been exposed to family planning
messages in any media than their rural counterparts. This is especially true for messages on
television and in the print media. Residents of the hill areas are more likely to have heard family
planning messages in the media than residents of the mountains and terai. A higher proportion of
women living in the Mid-western development region have been exposed to family planning
messages in at least one of the media, compared with women in the other development regions. On
the other hand, men living in the Western region have the greatest exposure to family planning
messages in the media. Women living in the Mid-western hill subregion and men living in the
Western hill subregion have the greatest exposure to family planning messages in the media,
compared with all other residents.

Education impacts media exposure positively. For example, one in two uneducated women
had no exposure to family planning information in any media compared with just 5 percent of
women with an SLC and above. A similar pattern is observed for men.

94 * Family Planning

Table 5.20 Exposure to family planning messages
Percentage of ever-married women and men who heard or saw a family planning message on the radio or
television, or in a newspaper/magazine in the past few months, according to background characteristics, Nepal 2001

Women Men

Background
characteristic Radio
Tele-
vision
News-
paper/
maga-
zine
None of
these
three
media
sources
Number
of
women Radio
Tele-
vision
News-
paper/
maga-
zine
None of
these
three
media
sources
Number
of
men

Age
15-19 55.1 20.9 10.8 40.1 941 64.5 33.8 17.9 28.6 70
20-24 57.2 24.2 12.1 37.7 1,658 72.0 45.1 32.9 19.2 295
25-29 53.8 23.4 10.0 40.8 1,666 67.6 36.6 32.1 25.1 340
30-34 57.0 23.5 9.9 37.8 1,427 65.6 31.6 23.0 29.7 344
35-39 53.3 21.7 7.5 43.0 1,168 69.5 32.7 25.4 23.3 322
40-44 53.1 22.1 7.5 42.9 1,030 61.6 29.1 23.2 33.7 261
45-49 50.2 18.5 6.5 46.8 837 62.7 28.6 22.5 32.3 243
50-54 na na na na na 57.5 23.5 19.9 38.9 216
55-59 na na na na na 63.5 17.5 12.5 33.7 171

Residence
Urban 66.6 72.2 29.7 15.0 841 69.6 69.8 53.8 14.4 227
Rural 53.3 17.1 7.4 43.5 7,885 65.1 27.6 21.5 30.2 2,034

Ecological zone
Mountain 65.9 5.5 3.4 33.8 602 67.1 10.3 14.5 32.3 151
Hill 69.5 18.1 11.2 28.0 3,615 75.9 25.8 28.6 21.6 896
Terai 41.2 28.2 8.9 51.9 4,509 57.7 39.0 23.2 33.4 1,214

Development region
Eastern 59.2 35.3 12.3 36.9 2,098 65.5 36.4 27.6 28.4 583
Central 38.4 22.9 8.3 53.8 2,804 59.8 45.3 26.9 29.2 750
Western 60.1 22.1 14.1 35.2 1,771 73.3 26.7 30.0 24.3 436
Mid-western 75.0 9.6 5.5 24.7 1,197 64.2 10.0 12.6 35.4 295
Far-western 56.6 8.1 2.9 41.6 855 72.4 11.7 14.3 26.1 197

Subregion
Eastern Mountain 66.7 12.7 8.8 32.7 126 69.8 11.6 22.1 29.1 33
Central Mountain 76.7 6.8 3.8 22.8 209 69.2 17.9 17.1 29.9 59
Western Mountain 57.0 1.1 0.6 43.0 267 63.5 1.9 7.7 36.5 59
Eastern Hill 64.5 18.6 7.9 34.0 580 81.8 26.2 26.9 17.8 161
Central Hill 67.2 33.9 17.8 27.3 945 72.3 45.1 39.0 20.1 278
Western Hill 72.7 19.2 15.9 24.5 1,075 83.1 23.7 35.5 16.9 235
Mid-western Hill 79.1 2.4 2.4 20.9 648 67.5 3.8 10.5 32.5 143
Far-western Hill 57.0 0.9 1.3 42.8 368 70.9 3.5 8.1 28.6 80
Eastern Terai 56.3 44.3 14.5 38.5 1,393 58.4 42.7 28.4 32.8 389
Central Terai 17.1 18.6 3.4 72.8 1,651 50.0 49.3 20.2 35.3 413
Western Terai 40.7 26.5 11.2 51.6 696 61.9 30.2 23.5 33.0 201
Mid-western Terai 74.6 22.7 11.3 24.6 438 66.4 19.2 15.9 32.7 126
Far-western Terai 54.5 19.3 5.8 41.1 331 68.7 22.6 23.0 28.3 85

Education
No education 46.9 13.1 2.4 50.0 6,279 48.8 15.7 3.9 46.3 852
Primary 68.2 33.6 13.1 24.3 1,294 67.1 30.1 18.2 26.4 670
Some secondary 79.8 57.4 36.6 10.6 814 81.7 43.5 43.0 12.9 452
SLC and above 84.7 68.2 61.6 5.1 339 86.1 65.7 73.1 6.2 287

Total 54.6 22.4 9.5 40.8 8,726 65.5 31.9 24.7 28.6 2,261
na = Not applicable
SLC = School Leaving Certificate

Family Planning * 95



5.19 EXPOSURE TO SPECIFIC RADIO SHOWS ON FAMILY PLANNING

As part of a strong effort to inform women and men about family planning, the National
Health Education Information and Communication Center (NHEIC) has been launching radio
programs with technical assistance from the Johns Hopkins University/ Center for Communication
Programs (JHU/CCP) in Nepal. The 2001 NDHS asked women and men whether they had heard
specific radio programs through which family planning messages are broadcast. These radio
broadcasts are Jana swastha karyakram, the drama Ghanti heri haad nilaun, the song Ghanti heri
haad nilaun, and the drama Shriman shrimatile parewarbare kurakani gareko chhoto radio natak.

Table 5.21 shows that one in three women has listened to each of these four specific radio
broadcasts in the last few months. The percentage of women exposed to family planning messages
through these four programs has increased in the last five years from about one in four in 1996.
Younger women, urban women, women living in the hills, those living in the Mid-western
development region, married women, and women who have some secondary education have had the
greatest exposure to these radio shows. The pattern of exposure to these radio shows among men is
similar to that for women, although men are somewhat more likely to have been exposed to each of
these four shows than women. Exposure is higher among men living in the hills, married men, and
men who have completed their SLC than among their counterparts.

96 * Family Planning

Table 5.21 Exposure to specific radio shows on family planning
Percentage of ever-married women and men who have heard specific radio shows on family planning in the few months preceding the survey, by
background characteristics, Nepal 2001

Women Men

Background
characteristic
Jana
swastha
karyakram
Ghanti heri
haad
nilaun
(drama)
Ghanti heri
haad
nilaun
(song)
Shriman
shrimatile
1

Number
of
women
Jana
swastha
karyakram
Ghanti heri
haad
nilaun
(drama)
Ghanti heri
haad
nilaun
(song)
Shriman
shrimatile
1

Number
of
men
Age

15-19 37.3 36.3 34.0 35.5 941 45.3 32.2 24.7 31.6 70
20-24 37.2 36.6 33.2 34.0 1,658 56.1 53.1 39.8 42.8 295
25-29 33.7 32.5 29.2 31.5 1,666 50.7 44.9 32.4 39.8 340
30-34 36.5 35.6 32.3 34.8 1,427 46.5 42.1 29.2 33.7 344
35-39 32.0 30.2 28.2 30.0 1,168 52.5 48.0 36.3 39.9 322
40-44 32.1 31.6 29.3 30.3 1,030 50.3 43.6 32.9 34.6 261
45-49 29.9 30.7 28.0 29.7 837 50.6 44.9 33.4 35.0 243
50-54 na na na na na 46.3 43.5 31.2 38.5 216
55-59 na na na na na 51.1 48.2 31.6 33.8 171

Residence
Urban 43.0 40.3 33.8 39.2 841 53.1 46.5 31.0 37.0 227
Rural 33.5 32.9 30.4 31.7 7,885 50.1 45.4 33.4 37.4 2,034

Ecological zone
Mountain 46.3 39.1 36.5 40.8 602 52.6 52.0 40.8 40.2 151
Hill 45.7 46.8 43.1 44.7 3,615 65.3 65.1 49.1 53.1 896
Terai 23.8 22.3 20.1 21.5 4,509 39.1 30.3 20.5 25.3 1,214

Development region
Eastern 42.1 39.9 36.9 35.8 2,098 50.2 44.0 31.4 29.2 583
Central 21.3 20.9 19.4 21.3 2,804 42.4 38.5 32.9 31.9 750
Western 40.7 41.1 35.9 42.5 1,771 60.8 52.5 30.3 47.9 436
Mid-western 45.0 46.6 44.3 44.1 1,197 54.4 54.0 53.0 53.7 295
Far-western 30.9 25.9 23.1 23.6 855 52.7 48.5 16.1 34.0 197

Subregion
Eastern Mountain 50.3 48.2 47.3 43.6 126 61.6 60.5 48.8 40.7 33
Central Mountain 48.6 50.9 47.8 53.9 209 53.8 68.4 61.5 60.7 59
Western Mountain 42.5 25.7 22.7 29.2 267 46.2 30.8 15.4 19.2 59
Eastern Hill 58.0 51.8 50.1 47.1 580 64.5 64.0 51.0 47.6 161
Central Hill 45.3 44.0 41.0 43.2 945 60.2 64.9 57.4 47.6 278
Western Hill 50.1 53.5 46.5 54.4 1,075 78.8 75.2 44.0 59.8 235
Mid-western Hill 41.3 48.6 46.8 43.4 648 59.6 58.1 57.0 62.6 143
Far-western Hill 22.0 23.5 21.6 18.5 368 55.7 51.1 17.5 47.3 80
Eastern Terai 34.7 34.3 30.5 30.4 1,393 43.3 34.4 21.8 20.7 389
Central Terai 4.1 3.9 3.5 4.7 1,651 28.8 16.5 12.2 17.2 413
Western Terai 26.2 22.0 19.7 24.0 696 39.9 26.1 14.4 34.2 201
Mid-western Terai 53.1 49.7 46.7 49.1 438 54.1 54.6 53.5 49.2 126
Far-western Terai 32.6 27.8 24.3 26.3 331 46.5 52.5 19.6 29.7 85

Marital status
Married 34.5 33.8 30.8 32.6 8,342 51.0 45.9 33.5 37.8 2,198
Divorced/separated/
widowed 33.7 30.6 28.9 29.6 384 31.7 33.2 23.4 22.1 63


Education
No education 26.3 25.6 23.8 24.1 6,279 33.5 33.7 23.1 23.7 852
Primary 48.7 49.2 44.9 48.5 1,294 49.9 46.9 34.2 36.9 670
Some secondary 61.8 59.8 53.5 59.8 814 67.2 55.3 41.9 50.5 452
SLC and above 63.9 59.8 51.1 59.3 339 75.4 62.2 47.0 57.9 287

Total 34.4 33.6 30.8 32.4 8,726 50.4 45.5 33.2 37.3 2,261
na = Not applicable
SLC = School Leaving Certificate
1
Shriman shrimatile parewarbare kurakani gareko chhoto radio natak

Family Planning * 97



5.20 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS

When they visit women in the field or when women visit health facilities, family planning
fieldworkers and health providers are expected to discuss family planning issues, to discuss the
various options available, and, if encouraged, to motivate nonusers to adopt a method of family
planning. To get insight into the level of contact between nonusers and health workers, currently
married women were asked whether a family planning fieldworker had visited them during the 12
months preceding the survey and discussed family planning. In addition, women were asked whether
they had visited a health facility in the 12 months preceding the survey for any reason and whether
anyone at the facility had discussed family planning with them during the visit. Table 5.22 shows
fieldworkers discussed family planning with only 9 percent of nonusers during the 12 months
preceding the survey, while five times as many nonusers (40 percent) missed opportunities to discuss
family planning when they visited a health facility. At the same time, only 8 percent of nonusers
discussed family planning at a health facility. (One of the reasons for the low level of exposure to
family planning from fieldworkers could be the lack of emphasis on home visits by family planning
fieldworkers.) Eighty-six percent of women who could have been exposed to family planning
information did not discuss family planning during a field visit or at a health facility.

There is little difference in contact of nonusers with family planning providers by background
characteristics, suggesting a huge scope for improving dissemination of family planning information
throughout the country and improving the level of acceptance among nonusers.

98 * Family Planning

Table 5.22 Contact of nonusers with family planning providers
Among currently married women who are not using contraception, percentage who were visited by a
fieldworker who discussed family planning, percentage who visited a health facility and discussed family
planning, percentage who visited a health facility but did not discuss family planning, and percentage who
did not discuss family planning with a fieldworker or at a health facility in the 12 months preceding the
survey, by background characteristics, Nepal 2001


Background
characteristic
Women who
were visited
by a field
worker who
discussed
family planning
Women who
visited a
health facility
and discussed
family planning
Women who
visited a
health facility
but did not
discuss family
planning
Women who
did not discuss
family planning
with a field
worker or at a
health facility

Number
of
women

Age
15-19 4.1 4.3 30.6 92.7 819
20-24 7.8 8.2 51.0 85.9 1,258
25-29 11.6 10.4 48.0 82.2 973
30-34 10.6 9.8 43.1 83.7 641
35-39 12.0 10.2 30.8 82.2 481
40-44 9.6 6.6 25.9 86.4 451
45-49 7.2 2.8 22.5 91.5 439

Residence
Urban 6.4 5.4 46.9 89.3 299
Rural 9.0 8.0 39.0 86.0 4,762

Ecological zone
Mountain 7.4 9.4 31.3 86.4 391
Hill 6.2 7.3 38.0 88.2 2,184
Terai 11.3 8.0 42.1 84.4 2,487

Development region
Eastern 10.1 9.4 36.6 83.7 1,085
Central 9.3 6.8 36.3 87.6 1,606
Western 7.7 9.9 47.4 84.9 1,067
Mid-western 5.1 6.2 44.0 89.8 739
Far-western 11.8 5.5 33.3 84.9 564

Subregion
Eastern Mountain 3.5 12.9 35.9 85.3 65
Central Mountain 5.5 11.5 36.4 86.2 115
Western Mountain 9.6 7.1 27.0 86.9 211
Eastern Hill 5.9 6.6 33.2 89.4 352
Central Hill 5.4 7.0 26.7 90.0 442
Western Hill 8.5 9.9 47.3 84.0 670
Mid-western Hill 2.6 6.9 44.9 90.9 447
Far-western Hill 8.3 3.2 28.1 89.9 273
Eastern Terai 13.0 10.6 38.4 80.5 668
Central Terai 11.4 6.2 40.4 86.7 1,049
Western Terai 6.4 10.0 47.6 86.3 397
Mid-western Terai 10.5 5.7 51.5 85.8 203
Far-western Terai 16.7 6.6 43.9 78.9 169

Education
No education 9.1 7.4 36.3 86.6 3,785
Primary 8.3 7.9 43.9 85.8 726
Some secondary 7.6 10.7 53.5 84.8 408
SLC and above 8.2 10.9 63.0 81.3 142

Total 8.8 7.8 39.5 86.2 5,061
SLC = School Leaving Certificate

Family Planning * 99

5.21 DISCUSSION OF FAMILY PLANNING BETWEEN SPOUSES

Although discussion between husband and wife about contraceptive use is not a precondition
for the adoption of contraception, its absence may be an impediment to use. Interspousal
communication is thus an important intermediate step along the path to eventual adoption and
especially continuation of contraceptive use or sustained use of contraception. Lack of discussion
may reflect a lack of personal interest, hostility to the subject, or customary reticence in talking about
sex-related matters. To explore this subject, currently married women and men interviewed in the
2001 NDHS survey were asked the number of times they discussed family planning with their
spouse in the year preceding the survey.

Table 5.23 shows the percent distribution of currently married women and men who know
about family planning by the number of times they discussed family planning with their spouse in the
year before the survey. In general, women are less likely to report having discussed family planning
with their spouse than men. Fifty-nine percent of women never discussed family planning with their
husband in the past year, compared with 48 percent of men. Twenty-nine percent of women and
31 percent of men discussed family planning once or twice with their spouse, while 13 percent of
women and 21 percent of men discussed family planning with their spouse three or more times in the
past year. Interspousal communication is more common among women age 20-34 and men age 20-
39 than among younger or older women and men. Results from the 1996 NFHS indicate that there
has been little change in the extent of interspousal communication over the last five years.


Table 5.23 Discussion of family planning with spouse
Percent distribution of currently married women and men who know a contraceptive
method by the number of times they discussed family planning with their spouse in the
past year, according to age, Nepal 2001


Number of times family planning discussed with spouse


Age 0 1-2 3+ Missing Total
Number
of
women/
men

WOMEN
15-19 63.9 27.0 9.1 0.0 100.0 929
20-24 49.8 36.0 14.1 0.1 100.0 1,638
25-29 49.1 34.2 16.5 0.2 100.0 1,612
30-34 49.5 32.6 17.8 0.1 100.0 1,367
35-39 62.3 26.1 11.3 0.2 100.0 1,096
40-44 73.4 18.9 7.6 0.1 100.0 932
45-49 85.4 11.0 3.7 0.0 100.0 727

Total 58.6 28.7 12.6 0.1 100.0 8,300
MEN
15-19 46.4 32.6 19.6 1.4 100.0 70
20-24 38.4 34.2 27.4 0.0 100.0 287
25-29 36.2 41.5 22.2 0.0 100.0 338
30-34 40.5 36.2 23.1 0.2 100.0 338
35-39 37.1 35.5 27.2 0.2 100.0 313
40-44 48.5 28.8 22.6 0.0 100.0 255
45-49 64.0 23.7 12.3 0.0 100.0 235
50-54 63.0 24.2 12.7 0.0 100.0 198
55-59 82.0 9.0 8.7 0.2 100.0 154

Total 47.7 31.4 20.8 0.1 100.0 2,189


100 * Family Planning
The fact that both men and women in the same household were interviewed provides an
opportunity to link responses obtained from currently married women with those obtained from their
husband. A total of 840 couples who are currently using contraception were linked in this manner.
Table 5.24 shows the primary decisionmaker in the use of contraception among these couples. This
could shed some light on the degree of autonomy women exercise over their reproductive
decisionmaking. Findings from the survey indicate that using contraception is mainly a joint decision
among couples. Among women who say contraceptive use was a joint decision, 84 percent of their
husbands agree. There are discrepancies, however, among women who say contraceptive use was
mainly their decision or their husbands decision, more than three-quarters of their husbands say it
was a joint decision.


Table 5.24 Decision on use of contraception
Percent distribution of couples who are currently using contraception by husbands report on contra-
ceptive decisionmaking, according to wifes report on contraceptive decisionmaking, Nepal 2001


According to husband, using contraception is mainly:



According to wife, using
contraception is mainly:
Wife's
decision
His
decision
Joint
decision Other Total
Number
of
couples

Her decision 22.8 1.4 75.8 0.0 100.0 155
Her husband's decision 0.0 26.6 73.4 0.0 100.0 69
Joint decision 5.7 10.1 84.0 0.2 100.0 606

Total 8.5 10.0 81.4 0.1 100.0 840
Note: Total includes 5 couples with other response and 4 couples with missing information who are
not shown separately.



The 2001 NDHS also gathered information from 1,864 couples about their attitude toward
family planning. Women and men were separately asked their perception of their spouses attitude
toward family planning. Table 5.25 shows the percent distribution of couples by husbands actual
attitude toward family planning, according to the wifes perception of his attitude.

The data indicate that when wives report that their husband approves of family planning, they
are generally accurate. For example, in 97 percent of cases in which the wife reported that her
husband approved of family planning, the husband also said he approved. At the same time, in
87 percent of the cases when the wife reported that her husband disapproved of family planning, the
opposite was true, that is, the husband approved. This information reinforces the importance of
spousal communication and greater male involvement in reproductive decisionmaking to ensure the
success of family planning programs in Nepal.

Table 5.25 Wife's perception of husband's attitude toward family planning
Percent distribution of couples by husband's actual attitude toward family planning, according
to wife's perception of husband's attitude, Nepal 2001


Husband's actual attitude
toward family planning



Wife's perception of
husband's attitude toward
family planning
Approves Disapproves Don't know Total
Number
of
couples
Approves 96.7 2.7 0.6 100.0 1,518
Disapproves 86.6 10.5 2.9 100.0 180
Don't know 87.7 9.9 2.4 100.0 166

Total 94.9 4.1 1.0 100.0 1,864

Other Proximate Determinants of Fertility * 101
6
OTHER PROXIMATE DETERMINANTS
OF FERTILITY


This chapter focuses on the principal factors, other than contraception, that affect a womans
risk of becoming pregnant and thus help to determine fertility in Nepal. These factors include
nuptiality and sexual intercourse, postpartum amenorrhea and abstinence from sexual relations, and
termination of exposure to pregnancy. In many societies, marriage signals the onset of a womans
exposure to the risk of childbearing, postpartum amenorrhea and sexual abstinence affect the
intervals between births, and the onset of menopause marks the end of a womans reproductive life.
These factors determine the length and pace of reproductive activity and are therefore important for
understanding fertility.

The 2001 Nepal Demographic and Health Survey (NDHS) included questions on the
proximate determinants of fertility administered to all ever-married women. In this chapter, a
number of tables are based on all women, that is, they include both ever-married and never-married
women. In constructing these tables, the denominators have been expanded to represent all women
by multiplying the number of ever-married women by an inflation factor equal to the ratio of all
women to ever-married women reported in the Household Questionnaire. The inflation factors are
calculated by single year of age, either for the population as a whole or, in cases where the results are
presented by background characteristics, separately for each category of the characteristic in
question.
6.1 CURRENT MARITAL STATUS

The distribution of all women age 15-49 and all men age 15-59 according to their marital
status
1
is shown in Table 6.1. The data indicate that 18 percent of women of reproductive age in
Nepal have never married, 79 percent are currently married, 1 percent are divorced or separated, and
2 percent are widowed. Marriage is almost universal in Nepal. The proportion never married
declines sharply with increasing age from 60 percent of women in the age group 15-19 to less than 5
percent of women in the age group 25-29. Further evidence of the universality of marriage is seen
among women age 35 and over, more than 98 percent of whom have married.

Widowhood is the leading cause of marital disruption, followed by marital separation. The
proportion widowed increases steadily with age, from 1 percent or less among women under age 30
to 10 percent among women age 45-49. As in the case of widowhood, separation also rises with age
from 1 percent among those less than 35 years to nearly 3 percent among women age 35-39 (Table
6.1). The proportion of women who are widowed, divorced, or separated has decreased very slightly
when compared with the 1996 NFHS.

Table 6.1 also provides information on the marital status of men. More than a quarter of all
men between 15-59 have never been married. This figure is 10 percentage points higher than the
figure for women. Marriage is also universal among Nepalese men, which can be seen clearly by the
fact that only 5 percent of men in the age group 30-34 have never married. As expected, the
proportion of widowers increases with age, from less than 1 percent among men below age 34 to a
high of 9 percent among men age 55-59.

1
In the NDHS, a woman not yet cohabiting with her marriage partner is not considered currently married.
102 * Other Proximate Determinants of Fertility


Table 6.1 Current marital status
Percent distribution of women and men by current marital status, according to age, Nepal
2001


Marital status


Age
Never
married Married Divorced Separated Widowed Total
Number
of
women/
men

WOMEN
15-19 59.7 39.8 0.0 0.4 0.0 100.0 2,335
20-24 17.1 82.1 0.1 0.4 0.3 100.0 2,001
25-29 4.5 93.2 0.3 1.1 1.0 100.0 1,744
30-34 2.5 94.0 0.3 1.1 2.1 100.0 1,464
35-39 1.9 92.3 0.0 2.7 3.1 100.0 1,191
40-44 1.1 89.9 0.0 1.8 7.2 100.0 1,042
45-49 1.4 86.2 0.0 2.2 10.1 100.0 849

Total 17.9 78.5 0.1 1.1 2.4 100.0 10,626
MEN
15-19 88.7 11.3 0.0 0.0 0.0 100.0 619
20-24 43.5 55.4 0.4 0.7 0.0 100.0 521
25-29 16.2 83.4 0.0 0.0 0.5 100.0 406
30-34 4.8 93.9 0.2 0.7 0.5 100.0 362
35-39 1.4 96.5 0.5 0.4 1.2 100.0 326
40-44 0.9 96.8 0.0 0.7 1.6 100.0 263
45-49 1.3 95.6 0.0 0.0 3.1 100.0 246
50-54 0.2 93.2 1.3 0.5 4.8 100.0 217
55-59 1.8 88.9 0.0 0.0 9.3 100.0 174

Total 27.8 70.1 0.2 0.3 1.5 100.0 3,133


Data from the national censuses and the 2001 NDHS show that the proportion of never-
married women below age 25 has increased gradually over time (Table 6.2). Note that the census
data refer to formal marriage, whereas the 2001 NDHS refers to effective marriage (living with
husband). Except for the year 1981, a steady increase is observed across most age groups in the
proportion of women who never married over the period 1961-2001. This is a clear indication that
the age at marriage in Nepal has increased over the last 40 years.

Table 6.2 also shows the proportion of never-married males by age from 1961 through 2001.
As in the case of females, data indicate that there has been a gradual increase in the proportion of
males never married over the years. A proportionately larger change has been observed among the
younger age groups (15-19 and 20-24) indicating that age at marriage among males is increasing
faster among younger men. For example, in 1961, 63 percent of males in the age group 15-19 had
not married, which gradually increased to 79 percent in 1991 and 89 percent in 2001. This is an
indication of a gradual shift to later marriage.
Other Proximate Determinants of Fertility * 103

Table 6.2 Trends in proportion never married
Percentage of women and men who have never married, by age group, Nepal 1961-
2001

Age group 1961 1971 1981 1991
2001
NDHS


WOMEN


15-19 25.7 39.3 49.2 52.7 59.7

20-24 5.3 7.9 13.1 12.8 17.1
25-29 1.9 2.6 5.4 3.7 4.5
30-34 1.0 1.4 3.1 1.9 2.5
35-39 0.8 1.1 2.6 1.3 1.9
40-44 0.7 0.9 2.5 1.1 1.1
45-49 0.6 0.8 2.9 0.9 1.4
MEN


15-19 63.3 73.0 74.1 79.4 88.7

20-24 26.4 33.1 40.9 38.1 43.5
25-29 10.2 12.3 19.5 12.7 16.2
30-34 4.7 5.7 12.4 5.2 4.8
35-39 2.7 3.3 8.9 2.8 1.4
40-44 2.1 2.3 8.0 2.1 0.9
45-49 1.6 1.6 7.4 1.6 1.3
50-54 1.5 1.4 6.9 1.6 1.2
55-59 1.3 1.2 7.0 1.4 1.8
Source: Data for 1961-1991 are from the Central Bureau of Statistics, 1995:173.

6.2 POLYGYNY

Marital unions are predominantly of two types, those that are monogamous and those that are
polygynous. The distinction has social significance and possible fertility implications, although the
relationship between union type and fertility is complex and not well understood. In this survey, the
extent of polygyny in Nepal was measured by asking currently married women, Besides yourself,
how many other wives does your husband have? and men, Do you have more than one wife? and
if yes, How many?

The proportion of currently married women and men in a polygynous union is shown in
Table 6.3 according to age groups and selected background characteristics. Overall, less than
5 percent of currently married women and less than 3 percent of men in Nepal reported being in a
polygynous union. Older women and men are more likely to be in a polygynous union than younger
women and men. There are few differences in polygyny by urban-rural residence, ecological zone,
and development region. Women in the Eastern and Far-western terai subregions and men in the
Eastern mountain subregion are more likely to report being in a polygynous union (6 percent each)
than in any other subregion.

There is a weak inverse relationship between respondents education and polygynythe
proportion of married women in a polygynous union is 5 percent among uneducated women
compared with 3 percent among women who have at least SLC level of education. The
corresponding data for men is 4 percent and 1 percent, respectively. This indicates that as the level of
schooling increases, both women and men are less likely to be in a polygynous union.
104 * Other Proximate Determinants of Fertility

Table 6.3 Polygyny
Percentage of currently married women and men who are in a
polygynous marriage, by background characteristics, Nepal 2001

Women Men

Background
characteristic
Percent-
age
Number
of
women
Percent-
age
Number
of
men


Age

15-19 1.6 930 0.0 70
20-24 3.0 1,643 0.6 289
25-29 4.2 1,625 1.2 338
30-34 5.4 1,377 1.6 340
35-39 5.0 1,099 2.2 315
40-44 6.6 936 3.1 255
45-49 6.5 732 4.8 235
50-54 na na 4.3 202
55-59 na na 7.1 155

Residence
Urban 4.3 792 2.8 223
Rural 4.4 7,550 2.6 1,975

Ecological zone
Mountain 3.4 573 2.8 144
Hill 4.4 3,444 2.7 869
Terai 4.6 4,325 2.5 1,185

Development region
Eastern 5.4 2,002 3.5 569
Central 3.4 2,684 2.2 732
Western 4.2 1,693 1.7 421
Mid-western 4.9 1,150 2.9 285
Far-western 5.0 813 3.1 190

Subregion
Eastern Mountain 2.6 118 6.1 31
Central Mountain 3.5 197 1.8 57
Western Mountain 3.8 258 2.0 56
Eastern Hill 4.6 552 3.5 158
Central Hill 4.0 899 2.7 270
Western Hill 4.3 1,017 2.3 227
Mid-western Hill 5.0 627 2.3 140
Far-western Hill 4.7 349 3.2 75
Eastern Terai 6.1 1,332 3.3 380
Central Terai 3.1 1,588 1.9 406
Western Terai 4.0 676 1.0 194
Mid-western Terai 5.0 417 3.3 121
Far-western Terai 5.6 313 4.1 84

Education
No education 4.8 5,970 3.5 808
Primary 3.6 1,247 2.0 660
Some secondary 3.6 793 2.6 445
SLC and above 2.5 332 1.3 284

Total 4.4

8,342 2.6 2,198
Note: Total includes women with missing information on number of
cowives who are not shown separately
na = Not applicable
SLC = School Leaving Certificate


Other Proximate Determinants of Fertility * 105
6.3 AGE AT FIRST MARRIAGE

Marriage marks the point in a womans life at which childbearing becomes socially
acceptable. Women who marry early will on average, have a longer exposure to the risk of
becoming pregnant, and therefore, early age at first marriage often implies early age at childbearing
and higher fertility in a society. Information on age at first marriage was obtained by asking women
for the month and year or age when they started living together with their first husband.

Table 6.4 shows that the median age at first marriage for ever-married women in Nepal age
15-49 is 16.6 years. The median age at first marriage has risen slowly over the last 25 years or so,
from 16.1 years among the cohort of women currently age 45-49 to 16.8 years among the cohort of
women age 20-24 (representing more recent marital patterns).

Table 6.4 also provides information on age at first marriage among ever-married men. On
average men marry about three years later than women, with the median age at marriage for men age
15-59 being 19.7. The data show that over the years, there has been no change in the median age at
marriage among males.

Table 6.4 also examines the median age at marriage for women and men by selected
background characteristics. Rural women marry about a year earlier than urban women, and rural
men marry two years earlier than urban men. Women and men in the terai marry about a year earlier
than women and men in the hills. Among the development regions, the Eastern development region
has the highest median age at marriage for both women and men (17.1 years and 20.3 years,
respectively) and the Far-western region has the lowest (16.1 years and 19.0 years, respectively).
There is a strong positive relationship between education and age at first marriage. Women with no
education tend to marry two years earlier than women with some secondary education and three
years earlier than women with at least an SLC. The educational difference is less pronounced among
men.
6.4 AGE AT FIRST SEXUAL INTERCOURSE

In the 2001 NDHS, currently married women and ever-married men were asked about their
age at first sexual intercourse. Table 6.4 shows the median age at first sexual intercourse for ever-
married women and men. Since the question on age at first sexual intercourse was not asked of
women who were divorced, separated, or widowed, it is assumed that their age at first sexual
intercourse is the same as their age at first marriage in this table. Overall, the median age at first
sexual intercourse among Nepalese women age 15-49 is 16.7 years, which is nearly identical to the
median age at first marriage, implying that womens first sexual experience usually occurs within the
context of marriage (Table 6.4). There is little difference in the median age at first sexual intercourse
among women by age, indicating that the median age at first sexual intercourse for women has not
changed much over the years.

The median age at first sexual intercourse among men age 15-59 is 18.8 years (Table 6.4).
This suggests that women have their first sexual experience two years earlier than men. However,
men initiate sex about one year before marriage.



106 * Other Proximate Determinants of Fertility

Table 6.4 Median age at marriage and median age at first sexual intercourse
Median age at marriage and median age at first sexual intercourse among ever-
married women and men, by background characteristics, Nepal 2001

Women Men

Background
characterisitc
Median age
at marriage
Median age
at first sexual
intercourse
Median age
at marriage
Median age
at first sexual
intercourse
Age
20-24 16.8 16.9 18.7 17.8
25-29 16.9 16.9 20.0 19.0
30-34 16.7 16.8 20.1 19.1
35-39 16.6 16.8 20.3 19.4
40-44 16.4 16.7 20.1 19.2
45-49 16.1 16.6 19.9 19.2
50-54 na na 20.1 19.1
55-59 na na 19.9 19.2

Residence
Urban 17.2 17.5 21.4 20.2
Rural 16.5 16.7 19.5 18.7

Ecological zone
Mountain 16.9 17.0 20.2 18.7
Hill 17.1 17.3 20.6 19.5
Terai 16.2 16.4 19.2 18.5

Development region
Eastern 17.1 17.3 20.3 19.4
Central 16.3 16.4 19.4 18.8
Western 16.9 17.1 20.2 18.8
Mid-western 16.4 16.6 19.4 18.6
Far-western 16.1 16.3 19.0 18.1

Subregion
Eastern Mountain 19.3 19.5 22.1 21.5
Central Mountain 17.1 17.3 19.8 18.8
Western Mountain 16.2 16.3 19.0 18.1
Eastern Hill 18.2 18.6 21.7 20.3
Central Hill 17.3 17.6 20.5 19.4
Western Hill 17.3 17.4 21.2 20.2
Mid-western Hill 16.6 16.7 19.7 18.9
Far-western Hill 16.0 16.2 19.1 18.2
Eastern Terai 16.6 16.8 19.7 18.9
Central Terai 15.8 15.9 19.0 18.5
Western Terai 16.5 16.6 18.7 18.1
Mid-western Terai 16.4 16.5 19.0 18.5
Far-western Terai 16.1 16.3 19.1 18.0

Education
No education 16.3 16.5 19.8 19.1
Primary 16.8 16.8 18.8 18.2
Some secondary 17.4 17.5 19.8 18.8
SLC and above 19.5 19.6 21.4 20.2

Total 16.6 16.7 19.7 18.8
Note: Total includes women age 15-19 who are not shown separately because less
than 50 percent were married or had had sexual intercourse by age 15. Since the
question on age at first sexual intercourse was not asked of women who were
divorced, separated or widowed, it is assumed that their age at first sexual intercourse
is the same as their age at marriage.
na = Not applicable
SLC = School Leaving Certificate

Other Proximate Determinants of Fertility * 107



Rural men initiate sex a year and a half earlier than urban men. Men living in the terai
initiate sex about a year earlier than men living in the mountains or hills. Men residing in the Far-
western development region have sex earlier than men living in any other development region. Men
with no education have their first sexual experience a year earlier than men with at least an SLC.
6.5 RECENT SEXUAL ACTIVITY

In the absence of effective contraception, the probability of becoming pregnant is related to
the frequency of intercourse. Information on sexual activity, therefore, can be used to refine
measures of exposure to pregnancy. In the 2001 NDHS, women were asked how long ago their last
sexual activity occurred. Even though most women were embarrassed to answer this question at first,
field observations showed that with some probing, most women did answer the question, and for the
most part, they seemed to be honest with their answers.

Table 6.5 provides information on the timing of last sexual intercourse for currently married
women of reproductive age. Overall, 71 percent of married women were sexually active in the four
weeks preceding the survey, 23 percent had had sexual intercourse within one year but not in the four
weeks before the survey, while 5 percent had had their most recent sexual intercourse one or more
years before the survey.

The relationship between recent sexual activity and age follows a bell-shaped pattern with a
plateau at age 30-39 and lower percentages at younger and older ages. A similar pattern is observed
for marital duration, with a peak among those women who have been married for 15-19 years.

The proportion of currently married women sexually active in the last four weeks is higher in
urban areas than in rural areas. Women living in the hills are less sexually active (68 percent) than
women residing in the mountains and terai. Women residing in the Western region were least likely
to be sexually active in the four weeks prior to the survey (65 percent), and women residing in the
Eastern region were the most likely (75 percent). Sexual activity in the past four weeks ranges from
a low of 58 percent among women living in the Western hill subregion to a high of 78 percent among
women living in the Central hill subregion. There is little variation in recent sexual activity by
womens level of education.

The 2001 NDHS data show that the type of contraceptive method currently used is related to
the timing of sexual activity, with users more likely than nonusers to have had sex recently. Among
contraceptive users, those who use spacing methods are more likely to be sexually active than those
using sterilization.


108 * Other Proximate Determinants of Fertility

Table 6.5 Recent sexual activity: women

Percent distribution of currently married women by timing of last sexual intercourse, according to background
characteristics, Nepal 2001


Timing of last sexual intercourse



Background
characteristic
Within
the last
4 weeks
Within
1 year
1

One or
more years Missing Total

Number
of
women

Age

15-19 68.4 28.5 2.4 0.7 100.0 930

20-24 67.9 26.6 4.5 1.0 100.0 1,643
25-29 70.9 23.7 4.9 0.5 100.0 1,625
30-34 76.8 18.6 3.9 0.7 100.0 1,377
35-39 76.6 18.8 3.8 0.8 100.0 1,099
40-44 70.7 22.5 6.2 0.7 100.0 936
45-49 62.2 26.7 10.5 0.6 100.0 732

Marital duration
Married only once
0-4 years 68.9 27.2 2.9 1.0 100.0 1,652
5-9 years 66.9 26.7 5.7 0.7 100.0 1,569
10-14 years 75.2 19.7 4.6 0.5 100.0 1,368
15-19 years 76.0 19.3 4.0 0.7 100.0 1,114
20-24 years 73.7 21.2 4.1 0.9 100.0 873
25+ years 66.7 23.8 9.1 0.5 100.0 1,184
Married more than once 73.1 23.4 3.1 0.5 100.0 581

Residence
Urban 79.0 16.2 4.1 0.6 100.0 792
Rural 70.1 24.2 4.9 0.7 100.0 7,550

Ecological zone
Mountain 73.1 21.5 4.8 0.6 100.0 573
Hill 67.5 25.4 6.5 0.7 100.0 3,444
Terai 73.5 22.2 3.6 0.8 100.0 4,325

Development region
Eastern 75.1 19.2 4.7 1.0 100.0 2,002
Central 74.1 22.6 2.8 0.4 100.0 2,684
Western 64.7 26.9 7.7 0.8 100.0 1,693
Mid-western 68.9 26.0 4.9 0.1 100.0 1,150
Far-western 66.7 25.8 5.9 1.7 100.0 813

Subregion
Eastern Mountain 77.4 16.8 4.8 1.0 100.0 118
Central Mountain 73.5 22.8 3.8 0.0 100.0 197
Western Mountain 70.9 22.6 5.6 0.9 100.0 258
Eastern Hill 74.0 18.8 6.4 0.8 100.0 552
Central Hill 78.4 17.1 4.0 0.5 100.0 899
Western Hill 58.3 31.8 9.0 0.9 100.0 1,017
Mid-western Hill 64.8 29.6 5.5 0.0 100.0 627
Far-western Hill 60.3 30.6 7.5 1.6 100.0 349
Eastern Terai 75.3 19.6 4.0 1.1 100.0 1,332
Central Terai 71.7 25.7 2.1 0.5 100.0 1,588
Western Terai 74.3 19.4 5.7 0.6 100.0 676
Mid-western Terai 73.4 22.2 4.1 0.4 100.0 417
Far-western Terai 73.3 21.0 3.8 1.9 100.0 313

Education
No education 70.9 23.3 5.0 0.7 100.0 5,970
Primary
71.9 23.1 4.6 0.5 100.0 1,247
Some secondary 69.6 24.7 5.1 0.6 100.0 793
SLC and above 72.6 23.8 2.3 1.2 100.0 332

Current contraceptive
Female sterilization 78.4 18.8 2.7 0.1 100.0 1,252
Pill 92.1 7.9 0.0 0.0 100.0 135
IUD 94.5 5.5 0.0 0.0 100.0 34
Condom 91.8 8.2 0.0 0.0 100.0 241
Periodic abstinence 91.0 6.8 2.2 0.0 100.0 94
Other method 86.4 12.4 1.1 0.1 100.0 1,525
No method 62.4 29.5 7.0 1.1 100.0 5,061


Total 71.0 23.4 4.9 0.7 100.0 8,342

Note: Figures in parentheses are based on 25-49 unweighted cases.
SLC = School Leaving Certificate
1
Excludes women who had sexual intercourse within the last 4 weeks


Other Proximate Determinants of Fertility * 109
Table 6.6 provides information on recent sexual activity for ever-married men age 15-59.
Eighty-two percent of men had sex within the last four weeks, 14 percent had their last instance of
sexual intercourse within the last year, and 5 percent had their most recent sexual experience one or
more years ago.


Table 6.6 Recent sexual activity: men
Percent distribution of ever-married men by timing of last sexual intercourse, according to background
characteristics, Nepal 2001


Timing of last sexual intercourse


Background
characteristic
Within
the last
4 weeks
Within
1 year
1

One or
more years Total

Number
of
men

Age
15-19 94.9 5.1 0.0 100.0 70
20-24 87.8 11.4 0.8 100.0 295
25-29 83.8 15.7 0.5 100.0 340
30-34 84.4 13.7 1.9 100.0 344
35-39 86.4 11.0 2.6 100.0 322
40-44 83.6 12.5 3.9 100.0 261
45-49 81.4 13.7 4.9 100.0 243
50-54 74.4 15.4 10.2 100.0 216
55-59 51.7 23.8 24.6 100.0 171

Marital status
In polygyous union 83.1 13.2 3.7 100.0 327
In monogamous union 83.9 14.1 2.0 100.0 1,869
Divorced/separated/widowed 4.9 9.9 85.2 100.0 65

Residence
Urban 76.9 19.0 4.1 100.0 227
Rural 82.0 13.3 4.7 100.0 2,034

Ecological zone
Mountain 81.5 12.2 6.3 100.0 151
Hill 80.0 15.8 4.2 100.0 896
Terai 82.6 12.6 4.7 100.0 1,214

Development region
Eastern 77.3 17.4 5.3 100.0 583
Central 85.1 11.0 3.8 100.0 750
Western 78.2 15.5 6.3 100.0 436
Mid-western 83.7 12.7 3.6 100.0 295
Far-western 84.2 12.0 3.8 100.0 197

Subregion
Eastern Mountain 81.4 14.0 4.7 100.0 33
Central Mountain 80.3 12.8 6.8 100.0 59
Western Mountain 82.7 10.6 6.7 100.0 59
Eastern Hill 75.4 19.8 4.8 100.0 161
Central Hill 81.9 14.7 3.4 100.0 278
Western Hill 79.5 14.8 5.6 100.0 235
Mid-western Hill 80.5 17.3 2.2 100.0 143
Far-western Hill 83.0 11.4 5.6 100.0 80
Eastern Terai 77.7 16.7 5.5 100.0 389
Central Terai 88.0 8.3 3.7 100.0 413
Western Terai 76.7 16.3 7.1 100.0 201
Mid-western Terai 87.0 8.9 4.0 100.0 126
Far-western Terai 86.6 11.8 1.6 100.0 85

Total 81.5 13.8 4.6 100.0 2,261

1
Excludes men who had sexual intercourse within the last 4 weeks


110 * Other Proximate Determinants of Fertility

In general, as age increases, the proportion of males having sexual intercourse in the last four
weeks decreases. For example, compared with 95 percent of men age 15-19 who were sexually
active in the last four weeks, the corresponding data for men age 30-34 is 84 percent, and for men
age 55-59, it is 52 percent.

There is virtually no difference in the timing of last sexual intercourse among men in a
monogamous relationship or polygynous relationship. About 5 percent of males who are not
currently in a marital union were sexually active in the last four weeks. A higher proportion of rural
males (82 percent) had had sexual intercourse within the last four weeks than their urban
counterparts (77 percent). Although there is no significant relationship between recent sexual
intercourse and ecological zone, some relationship by development region can be observed. Men in
the Eastern development region are the least likely to have had sex in the last four weeks
(77 percent), and men residing in the Central region the most likely (85 percent).
6.6 POSTPARTUM INSUSCEPTIBILITY

Postpartum amenorrhea refers to the interval between childbirth and the return of
menstruation. During this period, the risk of pregnancy is much reduced. The length of protection
from conception after childbirth depends on the duration and intensity of breastfeeding (which plays
a role in the delayed resumption of menstruation after birth) and the length of time before sexual
intercourse is resumed. Women who gave birth during the five years prior to the survey were asked
about the duration of postpartum amenorrhea and sexual abstinence. Women are considered
insusceptible if they are not exposed to the risk of pregnancy, either because they are amenorrheic or
are still abstaining from sex after a birth.

In the absence of contraception, variations in postpartum amenorrhea and abstinence are the
most important determinants of the interval between birth and pregnancy. In some populations,
differentials across subgroups in the duration of postpartum amenorrhea and abstinence may also
indicate incipient changes in traditional postpartum practices. A shortening of the period of
postpartum insusceptibility has implications for the provision of family planning services to recent
mothers.

Table 6.7 presents the percentage of births in the last three years for which mothers are
postpartum amenorrheic, abstaining, and insusceptible by the number of months since the birth.

The median length of postpartum amenorrhea is 11.1 months in Nepal, and the median length
of abstinence from sex during the postpartum period is 2.2 months. The median length of postpartum
insusceptibility is 11.4 months. The period of postpartum amenorrhea is considerably longer than
the period of postpartum abstinence and is therefore a principal determinant of the length of
postpartum insusceptibility to pregnancy in Nepal.

Virtually all women are insusceptible to pregnancy within the first two months after a birth,
and both amenorrhea and abstinence are important factors in their insusceptibility. However, starting
from the second month after birth, the contribution of abstinence to the period of insusceptibility is
greatly reduced as more women resume sexual relations. At 10-11 months after birth, one-half of all
women are still amenorrheic, while only 3 percent are still abstaining. By 18-19 months postpartum,
fewer than one in six women are insusceptible (18 percent), largely because of amenorrhea (15
percent). Only 4 percent of postpartum women are still abstaining at a duration of 18-19 months.
Other Proximate Determinants of Fertility * 111

Table 6.7 Postpartum amenorrhea, abstinence and insusceptibility
Percentage of births in the three years preceding the survey for which mothers
are postpartum amenorrheic, abstaining, and insusceptible, by number of
months since birth, and median and mean durations, Nepal 2001


Percentage of births for which the mother is:
Months since
birth Amenorrheic Abstaining Insusceptible
Number
of
births
<2 95.2 86.7 97.6 166
2-3 86.9 41.5 91.0 223
4-5 73.5 16.1 76.7 291
6-7 61.0 9.0 62.0 220
8-9 67.1 11.9 72.3 234
10-11 50.0 3.0 51.2 215
12-13 42.3 4.8 43.7 220
14-15 31.9 1.4 32.5 242
16-17 22.2 5.2 26.1 213
18-19 14.5 4.2 17.9 252
20-21 6.2 2.7 7.6 221
22-23 8.5 3.6 11.3 236
24-25 3.9 1.9 5.8 200
26-27 2.5 1.2 3.6 228
28-29 2.6 3.1 5.3 242
30-31 1.1 1.5 2.7 261
32-33 2.8 1.8 4.4 199
34-35 1.1 1.8 2.3 206

Total 31.5 10.1 33.8 4,071
Median 11.1 2.2 11.4 na
Mean 11.7 4.3 12.5 na
Note: Estimates are based on status at the time of the survey.
na = Not applicable



Given the postpartum abstinence plays an insignificant role in postpartum insusceptibility,
there is little variation in postpartum abstinence by background characteristics, and the variation by
postpartum amenorrhea and insusceptibility is similar. The median duration of postpartum
amenorrhea is slightly higher (by four months) for older women than for younger women
(Table 6.8). This difference can be explained to a large extent by the length and intensity of
breastfeeding and food supplementation to newborn children as well as the dietary intake of mothers.

The urban-rural difference in postpartum amenorrhea is more pronounced. For example,
postpartum amenorrhea among rural women is 11 months, while it is only four months for urban
women. This could be because the frequency and intensity of breastfeeding is higher among rural
women than among urban women, with supplementation taking place at an earlier age among urban
children than among rural children.

Variations in these measures are rather small by ecological region; however, some
differences by development region have been observed. The length of postpartum amenorrhea is
longest among women in the Mid-western development region and shortest among women in the
Western development region.
112 * Other Proximate Determinants of Fertility

Table 6.8 Median duration of postpartum insusceptibility by background characteristics
Median number of months of postpartum amenorrhea, postpartum abstinence, and
postpartum insusceptibility following births in the three years preceding the survey, by
background characteristics, Nepal 2001


Background
characteristic
Postpartum
amenorrhea
Postpartum
abstinence
Postpartum
insusceptibility
Number
of
births

Age

15-29 10.1 2.2 10.7 2,911
30-49 13.7 2.2 13.9 1,159

Residence
Urban 4.2 2.5 6.7 246
Rural 11.2 2.2 11.5 3,824

Ecological zone
Mountain 12.3 2.1 12.5 303
Hill 11.4 2.4 11.7 1,658
Terai 10.6 2.0 11.0 2,110

Development region
Eastern 9.5 2.2 10.3 938
Central 11.3 2.0 11.3 1,367
Western 8.7 2.5 10.0 706
Mid-western 13.9 2.2 14.6 612
Far-western 12.1 2.5 12.3 448

Subregion
Eastern Mountain 8.3 2.0 8.8 57
Central Mountain 8.9 2.9 8.9 101
Western Mountain 16.0 1.8 16.0 145
Eastern Hill 10.2 2.2 10.2 296
Central Hill 11.2 2.3 11.2 412
Western Hill 8.2 3.4 10.5 374
Mid-western Hill 15.4 2.2 15.9 374
Far-western Hill 11.6 3.7 11.6 201
Eastern Terai 9.3 2.3 10.5 585
Central Terai 11.6 1.8 11.6 854
Western Terai 9.3 1.9 10.0 332
Mid-western Terai 10.6 2.2 10.8 182
Far-western Terai 11.6 2.4 12.1 158

Education
No education 12.0 2.1 12.2 2,962
Primary 8.8 2.3 9.1 580
Some secondary 6.0 2.1 7.1 360
SLC and above 5.5 4.0 6.2 168

Total 11.1 2.2 11.4 4,071
Note: Medians are based on current status.
SLC = School Leaving Certificate


Postpartum amenorrhea is negatively associated with womens level of education. As the
level of education increases, the length of postpartum amenorrhea decreases. In fact, the length of
postpartum amenorrhea is more than twice as long among women with no formal schooling as
among those with an SLC or higher levels of education. This could be because educated women
provide supplementation much earlier than recommended, thereby decreasing the intensity and
frequency of breastfeeding and reducing the period of insusceptibility.
Other Proximate Determinants of Fertility * 113

6.7 TERMINATION OF EXPOSURE TO PREGNANCY

The chance of becoming pregnant declines with age. After age 30, an increasing proportion
of women become infecund or subfecund. Although the onset of infecundity is difficult to determine
for an individual woman, there are ways of estimating it for a population. Table 6.9 presents data on
the decreasing exposure to the risk of pregnancy due to menopause for women age 30.

For analytical purposes and to enable comparability across countries and across time, in this
report a woman is considered menopausal if she is neither pregnant nor postpartum amenorrheic and
has not had a menstrual period in the six months preceding the survey or if she reports herself as
being menopausal. The proportion of women who have reached menopause increases steadily with
age, from 3 percent among women age 30-34, to 14 percent of women age 42-43, and to 56 percent
among women age 48-49.


Table 6.9 Menopause
Percentage of currently married women
age 30-49 who are menopausal, Nepal
2001


Age
Percentage
menopausal
1

Number
of
women
30-34 3.4 1,377
35-39 5.2 1,099
40-41 9.0 401
42-43 14.2 383
44-45 27.3 314
46-47 45.2 319
48-49 55.7 250

Total 13.6 4,144

1
Percentage of all women who are not
pregnant and not postpartum amenorrheic
whose last menstrual period occurred six
or more months preceding the survey



Fertility Preferences * 115
7 FERTILITY PREFERENCES


Information on fertility preferences is important to measure the overall attitudes of society
toward childbearing and the general course of future fertility. Data on fertility preferences are also
useful for assessing the unmet need for family planning and the number of unwanted or mistimed
births in the population. These, together with data on contraceptive prevalence, provide an estima-
tion of the demand for family planning. In the 2001 NDHS, currently married (nonpregnant) women
and men were asked whether they want to have another child, and if so, how soon. Currently mar-
ried pregnant women were asked whether they wanted another child after the one they were expect-
ing and, if so, how long they would like to wait from the birth of the child they were expecting until
the birth of the next child. Additionally, women were asked for their desired family size and the
number of children they would choose to have if they could start afresh.

7.1 DESIRE FOR MORE CHILDREN

Table 7.1 shows the fertility preferences among currently married women and men by num-
ber of living children. More than two-fifths of currently married Nepalese women age 15-49 want
no more children, and an additional one-quarter either have been sterilized or say that they cannot
have any more children. Three in ten women want to have a child at some time in the future, 17 per-
cent say they would like to have another child after two years, and 12 percent say they would like to
have another soon (within two years). Only 1 percent say that they want another child but are not
sure when. Thus, the vast majority of women want to either space their next birth or limit childbear-
ing altogether. These women can be considered to be potentially in need of family planning services.

Desire for additional children is expected to drop progressively as the number of living chil-
dren increases. This pattern is observed in Table 7.1. A large majority (65 percent) of currently mar-
ried women who have no living children want to have a child soon, compared with 1 percent of cur-
rently married women with five living children. The proportion of women who want another child
later also decreases with the increase in the number of living children. Twenty-seven percent of
childless women want to have a child after two years. Among women who have one child, 57 per-
cent do not want to have another child at least for another two years. At the same time, the propor-
tion of women expressing a desire for no more children and who are sterilized or infecund increases
progressively with the increase in the number of living children.

Table 7.1 also shows that nearly one in two currently married men want no more children,
and one in five have been sterilized or say that they cannot have any more children.
1
Thirty percent
of married men want to have a child at some time in the future. Ten percent say that they would like
to have another child within two years, and 20 percent say they would like to have another child after
two years. About 1 percent said that they want another child but are not sure when.

1
Some of this difference may be because the number of living children includes current pregnancy for women,
but for men, it does not since the survey did not collect information on the pregnancy status of each wife.

116 * Fertility Preferences

Table 7.1 Fertility preferences by number of living children
Percent distribution of currently married women and men by desire for children, according to
number of living children, Nepal 2001


Number of living children
1



Desire for children 0 1 2 3 4 5 6+ Total

WOMEN
Have another soon
2
64.7 19.6 6.3 3.3 1.6 1.1 0.1 11.5
Have another later
3
26.7 56.6 16.6 6.1 2.0 2.3 0.3 16.6
Have another, undecided when 2.6 3.1 1.3 0.5 0.7 1.1 0.4 1.3
Undecided 0.7 1.8 2.1 1.1 1.3 0.7 0.9 1.4
Want no more 1.2 14.4 53.1 50.9 55.8 58.9 70.9 44.3
Sterilized/declare infecund
4
4.1 4.5 20.6 38.1 38.7 35.9 27.4 24.9

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 784 1,310 1,723 1,704 1,281 765 775 8,342
MEN
Have another soon
2
41.8 13.3 5.2 3.2 2.5 2.0 1.8 10.2
Have another later
3
25.9 54.5 19.1 8.8 5.9 3.9 1.1 19.5
Have another, undecided when 1.0 0.9 0.7 0.4 0.0 0.0 0.0 0.5
Undecided 0.0 2.8 1.4 2.5 2.0 1.0 0.6 1.7
Want no more 22.6 22.5 54.6 52.8 56.1 69.1 76.6 47.6
Sterilized/declare infecund
4
8.6 5.9 18.9 32.4 33.5 23.9 19.9 20.6

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 294 370 444 452 294 176 167 2,198
Note: Total includes women and men for whom information on fertility preferences is missing who
are not shown separately.
1
For women, includes current pregnancy
2
Wants next birth within 2 years
3
Wants to delay next birth for 2 or more years
4
Includes both female and male sterilization



The desire for additional children by number of living children among men is similar to that
observed for women, that is, the desire for additional children decreases progressively as the number
of living children increases. Forty-two percent of married men with no children want to have a child
soon, while only 2 percent of those with five or more children want to have another child soon.
Twenty-six percent of men who have no children want to have a child later. Among men who have
one living child, 55 percent want to have another child later, 23 percent do not want any more chil-
dren, and 6 percent have been sterilized or say that they are infecund. The proportion of men who
want another child after two years decreases with the number of living children. On the other hand,
the proportion of men expressing a desire for no more children increases progressively with the
number of living children. In contrast to just 1 percent of women, 23 percent of men with no living
children said that they do not want any children.
Fertility Preferences * 117
Table 7.2 presents the distribution of monogamous couples by desire for more children. This
table excludes women who stated that they are currently pregnant, since similar information on the
current pregnancy status of the wife(wives) was not collected from men. Overall, three in five cou-
ples agree on their desire either to have more children (22 percent) or to have no more children (36
percent). This shows a relatively high level of agreement among couples on their desire for children.
An examination of the desire for more children among monogamous couples by place of residence
shows that couples residing in urban areas and those residing in the mountain ecological zone are
more likely to agree on their desire for more children than couples residing in rural areas or the hills
or terai. There is little difference in the level of agreement among couples by development region.
Overall, a higher percentage of husbands want more children than wives; for example, the percentage
of monogamous couples in which the husband wants more children but the wife does not want any
more is 7 percent, compared with only 3 percent of couples in which the reverse is true. However,
this difference is more obvious among rural couples, couples residing in the mountain zone, and
couples living in the Far-western region.


Table 7.2 Desire for more children among monogamous couples
Percent distribution of monogamous couples by desire for more children, according to place of residence, Nepal 2001

Place of
residence
Both
want
more
Husband
more/wife
no more
Wife more/
husband
no more
Both want
no more
Husband or
wife steri-
lized/wife
infecund
One or
both unde-
cided/
missing Total
Number
of
couples

Residence

Urban 16.4 4.5 1.5 45.8 30.2 1.6 100.0 167
Rural 22.2 7.3 3.1 35.0 30.7 1.8 100.0 1,445

Ecological zone
Mountain 31.0 7.5 1.0 41.8 17.3 1.4 100.0 108
Hill 21.9 8.7 3.6 43.4 20.3 2.1 100.0 624
Terai 20.3 5.7 2.6 30.2 39.6 1.5 100.0 880

Development region
Eastern 19.9 7.9 2.4 36.8 31.9 1.1 100.0 415
Central 21.1 7.6 2.5 36.3 30.9 1.6 100.0 551
Western 22.4 4.2 4.0 35.9 29.8 3.7 100.0 294
Mid-western 21.4 6.2 4.2 37.9 28.8 1.6 100.0 212
Far-western 27.2 9.3 1.7 30.9 30.5 0.4 100.0 140

Total 21.6 7.0 2.9 36.1 30.6 1.7 100.0 1,612


7.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS

Table 7.3 shows the percent distribution of currently married women and men who want no
more children by number of living children and selected background characteristics. Three-fourths of
urban women, compared with two-thirds of rural women, want to stop bearing children. There is lit-
tle difference in womens desire to limit childbearing by ecological zone. The desire to limit child-
bearing is lowest among women in the Far-western development region and highest in the Eastern
region. The desire to limit childbearing is more apparent at higher levels of education than at lower
levels. For example, 68 percent of women with no education want no more children, compared with
59 percent of women with at least an SLC.

118 * Fertility Preferences

Urban-rural differences in the desire to limit childbearing are more obvious among women
than among men. Table 7.3 shows only a 4 percentage point difference for men, compared with a 10
percentage point difference among women. However, differences by ecological region are more
pronounced for men than women. The desire to stop childbearing is lowest among men who live in
the terai, with little difference between men who live in the mountains or hills. Men who live in the
Far-western development region are less likely to want to limit childbearing than men in the other
regions. Similar to women, mens desire to stop childbearing varies inversely with education.

The pattern in the desire to limit childbearing by background characteristics does not change
much when currently pregnant women and husbands of currently pregnant women are excluded from
the table.


Table 7.3 Desire to limit childbearing
Percentage of currently married women and men who want no more children, by number of living children and background characteris-
tics, Nepal 2001
Number of living children: women
1
Number of living children: men

Background
characteristic 0 1 2 3 4 5 6+ Total 0 1 2 3 4 5 6+ Total

Residence
Urban 2.4 26.4 89.0 94.9 96.0 93.4 90.3 74.8 (25.0) 22.4 70.4 71.2 (70.6) * * 58.3
Rural 1.9 14.9 69.3 85.6 90.7 88.7 88.5 64.7 24.6 23.8 60.0 63.4 68.0 75.5 82.5 53.9

Ecological zone
Mountain 3.4 16.2 69.3 86.5 90.9 90.0 86.9 64.9 25.6 24.5 65.9 (84.8) (91.0) * * 58.7
Hill 2.4 21.0 77.5 88.1 92.7 91.1 87.0 67.8 28.0 22.4 69.9 73.6 77.1 79.7 87.3 59.5
Terai 1.3 12.2 67.1 85.4 90.1 87.4 90.4 64.0 21.2 24.4 55.2 57.1 60.8 69.2 77.3 50.1

Development region
Eastern 1.8 19.3 73.4 90.7 92.8 90.7 91.0 68.8 22.4 21.0 51.3 55.9 67.0 (63.1) (75.6) 48.8
Central 1.5 18.6 69.0 83.2 93.5 92.2 92.9 65.1 23.5 25.7 69.0 68.9 73.2 (87.0) (91.5) 58.9
Western 2.9 18.9 80.4 86.9 89.8 84.2 80.8 66.6 28.6 18.4 66.8 73.4 65.2 (76.4) (83.7) 58.7
Mid-western 1.5 5.7 68.7 89.9 86.9 87.4 90.7 63.9 26.5 32.3 64.5 55.7 63.0 (72.7) * 53.7
Far-western 2.0 8.7 58.6 80.7 88.0 87.1 80.2 59.9 20.8 20.2 39.3 62.9 66.3 (67.9) (65.9) 45.2

Education
No education 2.5 12.4 63.2 84.5 90.3 88.7 88.3 67.7 41.6 36.1 59.7 65.1 67.7 76.4 79.7 60.3
Primary 0.0 19.1 78.0 90.6 95.1 91.1 96.3 61.1 20.2 20.0 55.1 60.5 70.5 (76.0) (92.8) 52.1
Some secondary 3.0 19.3 92.7 92.7 97.9 95.3 69.3 59.9 5.6 17.9 62.5 66.2 67.8 79.8 * 47.1
SLC and above (0.0) 28.5 88.8 (97.8) * * * 58.5 (12.6) (16.8) 73.2 67.0 (63.2) * * 54.2

Total 1.9 16.2 71.8 86.5 91.2 89.0 88.6 65.6 24.6 23.6 61.4 64.2 68.2 75.4 83.3 54.4

Excluding currently
pregnant

1.9

16.4

72.3 86.9

91.7

89.4

88.2

66.2

24.6

26.2

62.6

64.4

68.4

74.4

83.3

55.5

Note: Women and men who have been sterilized are considered to want no more children. Figures in parentheses are based on 25-
49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed.
SLC = School Leaving Certificate
1
Includes current pregnancy


Fertility Preferences * 119
7.3 NEED FOR FAMILY PLANNING SERVICES

Currently married women who say that they do not want any more children or that they want
to wait two or more years before having another child, but are not using contraception, are consid-
ered to have an unmet need for family planning.
2
Women who are using family planning methods are
said to have a met need for family planning. Together they constitute the total demand for family
planning.

Table 7.4 shows the need for family planning among currently married women by selected
background characteristics. Twenty-eight percent of currently married women in Nepal have an un-
met need for family planning services, 11 percent for spacing and 16 percent for limiting births. At
the same time, 39 percent of currently married women are currently using a contraceptive method,
with 4 percent using for spacing and 36 percent using for limiting. Taken together, two in three
Nepalese women have a demand for family planning. In other words, if all women with unmet need
for spacing and limiting were to use family planning, the contraceptive prevalence rate would in-
crease from 39 percent to 67 percent. Fifty-nine percent of the demand for family planning is cur-
rently being satisfied. This implies that Nepals family planning program has some way to go to meet
both the spacing and limiting needs of couples.

As expected, unmet need for spacing is higher among younger women, while unmet need
for limiting is higher among older women, with total unmet need being lowest among women age
45-49. Unmet need is twice as high among women in rural areas as among women in urban areas.
Unmet need for family planning is lower among women in the terai than in the other ecological
zones. Unmet need is lowest among women residing in the Eastern development region and highest
among women living in the Western and Far-western regions. One-fifth of women living in the
Eastern terai subregion have an unmet need for family planning, compared with 37 percent of
women living in the Western mountain subregion. Unmet need for family planning is negatively as-
sociated with womens level of education, ranging from a high of 28 percent among women with no
education to a low of 21 percent among women with at least an SLC.

A comparison with the 1996 NFHS data shows that the unmet need for family planning has
decreased from 31 percent in 1996 to 28 percent in 2001 (Pradhan et al., 1997). During the same pe-
riod, the percentage of demand satisfied increased from 48 percent in 1996 to 59 percent in 2001.
These data provide good information to program managers who plan family planning services, pro-
vider training, and commodity and equipment procurement. Through the results of this research,
family planning program managers can identify spacing and limiting needs, but it must be clarified
that expressed needs do not necessarily equate with what methods couples would choose to satisfy
those needs. It should not be a foregone conclusion that limiting needs are only satisfied with sterili-
zation services. Limiting needs can be satisfied with spacing methods. A voluntary family planning
program requires informed choice and a comprehensive range of methods from which men and
women can choose for either limiting or spacing.

2
For an exact description of the calculation, see footnote 1, Table 7.4.

120 * Fertility Preferences

Table 7.4 Need for family planning
Percentage of currently married women with unmet need for family planning and with met need for family planning, and the total demand
for family planning, by background characteristics, Nepal 2001

Unmet need for
family planning
1

Met need for family planning
(currently using)
2

Total demand for
family planning



Background
characteristic
For
spacing
For
limiting Total
For
spacing
For
limiting Total
For
spacing
For
limiting Total



Percentage
of demand
satisfied


Number
of
women

Age
15-19 33.4 2.2 35.6 10.7 1.2 12.0 44.1 3.5 47.6 25.2 930
20-24 23.8 9.4 33.2 8.6 14.8 23.4 32.4 24.2 56.6 41.4 1,643
25-29 10.8 21.0 31.9 2.9 37.2 40.1 13.8 58.2 72.0 55.7 1,625
30-34 4.1 23.2 27.2 1.7 51.8 53.5 5.7 74.9 80.7 66.3 1,377
35-39 1.1 23.2 24.3 0.5 55.7 56.2 1.6 78.9 80.6 69.8 1,099
40-44 0.5 20.5 20.9 0.0 51.9 51.9 0.5 72.3 72.8 71.3 936
45-49 0.0 11.5 11.5 0.0 40.0 40.0 0.0 51.5 51.5 77.7 732

Residence
Urban 6.5 9.2 15.8 7.5 54.7 62.2 14.1 63.9 78.0 79.8 792
Rural 11.9 17.1 29.0 3.4 33.5 36.9 15.3 50.6 66.0 56.0 7,550

Ecological zone
Mountain 9.6 22.9 32.5 3.0 28.7 31.8 12.7 51.6 64.3 49.4 573
Hill 11.8 18.6 30.4 3.9 32.7 36.6 15.7 51.3 67.0 54.6 3,444
Terai 11.3 13.7 25.0 3.9 38.6 42.5 15.2 52.4 67.5 62.9 4,325

Development region
Eastern 8.8 15.3 24.1 5.5 40.3 45.8 14.2 55.6 69.8 65.6 2,002
Central 11.4 15.6 27.0 4.2 36.0 40.2 15.6 51.6 67.2 59.8 2,684
Western 11.7 18.8 30.5 2.8 34.1 36.9 14.5 52.9 67.4 54.8 1,693
Mid-western 12.8 16.6 29.4 2.4 33.3 35.7 15.3 49.9 65.2 54.9 1,150
Far-western 14.9 16.5 31.4 2.7 27.9 30.7 17.6 44.4 62.0 49.4 813

Subregion
Eastern Mountain 8.1 21.9 30.0 2.9 42.3 45.2 11.0 64.2 75.2 60.1 118
Central Mountain 9.7 18.8 28.4 5.9 35.9 41.8 15.5 54.7 70.2 59.5 197
Western Mountain 10.3 26.5 36.8 0.9 17.0 17.9 11.2 43.5 54.7 32.8 258
Eastern Hill 10.8 22.6 33.3 5.8 30.4 36.2 16.6 53.0 69.5 52.1 552
Central Hill 8.2 14.6 22.9 7.0 43.9 50.9 15.2 58.6 73.8 69.0 899
Western Hill 11.5 22.2 33.8 2.4 31.7 34.1 13.9 53.9 67.9 50.3 1,017
Mid-western Hill 14.9 17.8 32.7 1.9 26.9 28.7 16.8 44.7 61.4 46.8 627
Far-western Hill 17.7 13.7 31.4 0.9 20.9 21.8 18.6 34.5 53.2 40.9 349
Eastern Terai 8.0 11.7 19.7 5.6 44.3 49.8 13.5 56.0 69.5 71.7 1,332
Central Terai 13.5 15.7 29.2 2.4 31.5 33.9 15.9 47.2 63.1 53.7 1,588
Western Terai 12.0 13.6 25.6 3.4 37.8 41.2 15.4 51.4 66.8 61.7 676
Mid-western Terai 10.0 13.8 23.8 3.8 47.5 51.3 13.7 61.3 75.0 68.3 417
Far-western Terai 14.5 12.6 27.1 5.5 40.6 46.2 20.0 53.2 73.3 63.0 313

Education
No education 9.7 18.6 28.4 2.0 34.6 36.6 11.7 53.2 65.0 56.3 5,970
Primary 15.5 13.4 28.9 5.5 36.4 41.8 21.0 49.7 70.7 59.1 1,247
Some secondary 16.7 7.9 24.6 9.5 39.0 48.5 26.2 46.9 73.1 66.4 793
SLC and above 13.2 7.3 20.5 16.4 40.8 57.2 29.6 48.0 77.6 73.6 332

Total 11.4 16.4 27.8 3.8 35.5 39.3 15.2 51.9 67.1 58.6 8,342
SLC = School Leaving Certificate

1
Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrheic women who are not using family planning
and whose last birth was mistimed, and fecund women who are neither pregnant nor amenorrheic and who are not using any method of
family planning and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women
who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are
unsure when to have the birth unless they say it would not be a problem if they discovered they were pregnant in the next few weeks. Un-
met need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrheic women whose last child was unwanted, and
fecund women who are neither pregnant nor amenorrheic and who are not using any method of family planning and who want no more
children. Excluded from the unmet need category are pregnant and amenorrheic women who became pregnant while using a method (these
women are in need of a better method of contraception).
2
Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are unde-
cided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific
methods used are not taken into account here.

Fertility Preferences * 121


7.4 IDEAL FAMILY SIZE

In the 2001 NDHS information on ideal family size was gathered in two ways. Women and
men who had no living children were asked how many children they would like to have if they could
choose the number of children to have. Those with living children were asked how many children
they would like to have if they could go back to the time when they did not have any children and
could choose exactly the number of children to have. These questions are based on hypothetical
situations; therefore, the responses to them are expected to in part reflect societal norms prevalent in
the past as well as at present because respondents with larger families are more likely to be older and
have larger ideal size because of attitudes they acquired 20 to 30 years ago. Among women and men
who have not started childbearing, the data provide an idea of the total number of children these
women will have in the future.

Table 7.5 shows that most women and men (98 percent) were able to give a numeric response
to the question on ideal number of children. In general, the ideal number of children for Nepalese
women and men is only marginally different. Ever-married women want on average 2.6 children,
while ever-married men want on average 2.8 children. There was a small decline in the mean ideal
number of children among women between 1996 (2.9) and 2001 (2.6).

Forty-six percent of women and 39 percent of men express a preference for a two-child fam-
ily, while 34 percent of women and 38 percent of men express a preference for a three-child family.
Thirteen percent of women and 14 percent of men express an ideal family size of four children. A
small proportion of women and men expressed an ideal family size of five or more. Both women and
men in Nepal prefer a small family size. In general, women and men with four or more living chil-
dren prefer fewer children. For example, 92 percent of women with five children say that if they
could choose again, they would have fewer than five, and 72 percent of women with four children
would have fewer.

Table 7.6 shows the mean ideal number of children for ever-married women and men by age
and selected background characteristics. The mean ideal number of children for women increases
with age from 2.4 children among women age 15-19 to 3.0 among women age 45-49. In every age
group, rural women have a larger ideal family size than urban women. Overall, there is little differ-
ence in the mean ideal number of children by ecological and development region. Education varies
inversely with the mean ideal number of children, with a one-child difference between women with
no education and women with at least an SLC. The pattern in the mean ideal number of children by
background characteristics is similar for men and women.

122 * Fertility Preferences


Table 7.5 Ideal number of children
Percent distribution of ever-married women and men by ideal number of children, and mean ideal
number of children for ever-married women and men and for currently married women and men,
according to number of living children, Nepal 2001


Number of living children
1


Ideal number
of children 0 1 2 3 4 5 6+ Total


WOMEN

0 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0
1 6.2 11.2 4.2 2.3 1.1 0.6 0.2 3.9
2 56.8 56.7 67.1 38.4 36.5 27.4 18.5 45.8
3 26.7 24.2 22.4 48.1 34.3 44.4 38.6 33.7
4 6.9 6.0 4.8 8.4 24.6 19.9 29.8 12.7
5 1.4 0.7 0.4 0.8 1.2 4.2 5.3 1.5
6+ 0.2 0.1 0.1 0.3 0.6 1.1 2.9 0.6
Non-numeric responses 1.6 1.0 0.9 1.7 1.7 2.4 4.7 1.8

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 830 1,374 1,798 1,787 1,336 798 803 8,726

Mean ideal number of children
2

Ever-married women 2.4 2.3 2.3 2.7 2.9 3.0 3.3 2.6
Number 816 1,359 1,781 1,758 1,314 779 765 8,572

Currently married women 2.4 2.3 2.3 2.7 2.9 3.0 3.3 2.6
Number 774 1,297 1,707 1,675 1,260 745 739 8,198

MEN

1 4.2 4.0 2.7 1.6 0.6 2.3 0.9 2.4
2 40.7 46.6 50.5 35.3 35.8 21.0 27.3 39.4
3 36.8 39.7 31.1 41.9 33.9 47.4 36.5 37.6
4 10.5 8.3 12.0 14.5 22.1 16.8 20.0 14.0
5 1.9 0.8 2.0 3.3 2.0 7.7 5.0 2.7
6+ 2.6 0.3 0.7 0.6 2.6 1.6 6.4 1.6
Non-numeric responses 3.4 0.4 0.9 2.8 2.9 3.3 3.9 2.3

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 316 378 454 466 301 177 168 2,261

Mean ideal number of children
2

Ever-married men 2.7 2.6 2.6 2.8 3.0 3.1 3.2 2.8
Number 305 377 450 453 293 171 162 2,210

Currently married men 2.7 2.5 2.6 2.8 2.9 3.1 3.2 2.8
Number 285 368 440 439 286 170 161 2,150

1
For women, includes current pregnancy
2
Means are calculated excluding the women and men giving non-numeric responses.


Fertility Preferences * 123

Table 7.6 Mean ideal number of children by background characteristics
Mean ideal number of children for ever-married women and men, by age and background characteris-
tics, Nepal 2001

Age
Background
characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49
All
women
All
men

Residence

Urban 2.1 2.0 2.2 2.2 2.4 2.6 2.6 2.3 2.3
Rural 2.4 2.4 2.6 2.7 2.9 3.0 3.1 2.7 2.9

Ecological zone
Mountain 2.1 2.3 2.5 2.7 2.9 3.1 3.2 2.7 2.9
Hill 2.1 2.2 2.4 2.6 2.8 2.8 2.9 2.5 2.7
Terai 2.5 2.5 2.6 2.7 2.9 3.0 3.1 2.7 2.8

Development region
Eastern 2.3 2.4 2.4 2.6 2.8 2.9 3.0 2.6 2.7
Central 2.5 2.5 2.7 2.7 2.9 2.8 3.0 2.7 2.9
Western 2.1 2.1 2.2 2.4 2.6 2.7 2.9 2.4 2.7
Mid-western 2.3 2.3 2.6 2.9 3.2 3.3 3.2 2.8 2.9
Far-western 2.4 2.5 2.8 2.9 3.0 3.1 3.2 2.8 2.7

Subregion
Eastern Mountain 2.1 2.1 2.1 2.7 2.9 3.1 3.1 2.6 3.0
Central Mountain 2.0 2.2 2.4 2.3 2.7 2.7 2.9 2.4 2.7
Western Mountain 2.3 2.4 2.7 3.0 3.0 3.3 3.5 2.9 3.1
Eastern Hill 2.0 2.1 2.4 2.6 2.9 3.0 2.9 2.6 2.8
Central Hill 2.1 2.1 2.4 2.5 2.6 2.5 2.7 2.4 2.7
Western Hill 2.0 2.0 2.1 2.2 2.3 2.5 2.9 2.3 2.6
Mid-western Hill 2.3 2.3 2.6 3.1 3.4 3.5 3.2 2.8 2.8
Far-western Hill 2.5 2.7 2.9 3.1 3.2 3.3 3.2 2.9 2.7
Eastern Terai 2.4 2.5 2.5 2.6 2.8 2.9 3.0 2.6 2.7
Central Terai 2.8 2.7 2.9 2.8 3.0 3.0 3.2 2.9 3.1
Western Terai 2.3 2.3 2.5 2.6 3.0 2.9 3.0 2.6 2.7
Mid-western Terai 2.5 2.3 2.4 2.7 2.9 3.1 3.1 2.7 2.8
Far-western Terai 2.3 2.4 2.6 2.7 2.7 2.8 3.1 2.6 2.7

Education
No education 2.6 2.6 2.7 2.8 3.0 3.0 3.1 2.8 3.2
Primary 2.2 2.2 2.2 2.3 2.6 2.5 2.8 2.3 2.8
Some secondary 2.0 2.0 2.1 2.2 2.3 2.3 2.4 2.1 2.5
SLC and above 1.7 1.8 2.0 1.9 2.0 1.9 2.0 1.9 2.2

All women 2.4 2.4 2.5 2.7 2.9 2.9 3.0 2.6 na

All men 2.6 2.5 2.6 2.8 2.8 2.8 3.1 na 2.8
Note: Total for men includes men age 50-54 (mean 3.1) and 50-59 (mean 3.3) who are not shown sepa-
rately.
na = Not applicable
SLC = School Leaving Certificate



7.5 FERTILITY PLANNING

In the NDHS, women were asked a series of questions for each child born in the preceding
five years and any current pregnancy to determine whether a particular pregnancy was wanted then
(planned), wanted later (mistimed), or not wanted (unplanned). This information may in fact
underestimate unplanned childbearing since women may rationalize unplanned births and declare
them as planned once they occur.

124 * Fertility Preferences


Table 7.7 shows that more than one in five births in Nepal is unwanted, while two in three
births are planned and 14 percent are mistimed. In general, the proportion of unwanted births in-
creases with birth order, from 2 percent among second births to 51 percent among births of order
four and above. Unwanted births also generally increase with mothers age, rising from a low of 1
percent among mothers below 20 years of age to a high of 71 percent among mothers age 40-44.
Mistimed births are lowest among high order births (order four and above) and are highest among
births of order two. Mistimed births also tend to decrease with mothers age.


Table 7.7 Fertility planning status
Percent distribution of births in the five years preceding the survey (including cur-
rent pregnancies), by fertility planning status, according to birth order and mother's
age at birth, Nepal 2001


Planning status of birth




Birth order
and mother's
age at birth
Wanted
then
Wanted
later
Wanted
no
more Missing Total
Number
of
births

Birth order

1 83.8 15.5 0.1 0.6 100.0 1,868
2 75.4 22.4 1.6 0.6 100.0 1,770
3 66.8 14.1 18.8 0.3 100.0 1,338
4+ 42.2 7.1 50.5 0.3 100.0 2,752

Mothers age at birth
<20 76.5 22.0 0.9 0.6 100.0 1,448
20-24 74.0 17.9 7.7 0.4 100.0 2,674
25-29 60.8 11.5 27.4 0.3 100.0 1,862
30-34 49.7 4.4 45.4 0.5 100.0 1,028
35-39 33.5 1.6 64.5 0.3 100.0 504
40-44 26.9 1.1 71.4 0.6 100.0 192
45-49 * * * * 100.0 19

Total 64.1 13.8 21.6 0.4 100.0 7,729
Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases
and has been suppressed.



Another way of measuring unwanted fertility utilizes the data on ideal family size to calculate
what the total fertility rate would be if all unwanted births were avoided. This measure may also suf-
fer from underestimation to the extent that women are unwilling to report an ideal family size lower
than their actual family size. Despite these shortcomings, this information is useful in gauging the
potential demographic impact of eliminating unwanted births.

Table 7.8 shows the total wanted fertility rates and actual fertility rates for the three years
preceding the survey, by selected background characteristics. The wanted fertility rates are calculated
in the same manner as the total fertility rates, but unwanted births are excluded from the numerator.
Unwanted births are those that exceed the number mentioned as ideal by the respondent. This rate
represents the level of fertility that would have prevailed in the three years preceding the survey if all
unwanted births had been prevented.
Fertility Preferences * 125



The wanted fertility rate in Nepal is 2.5 births
per woman (a decline from the 1996 level of 2.9 chil-
dren per woman), 1.6 children less than the actual to-
tal fertility rate. This implies that the total fertility rate
is 64 percent higher than it would be if unwanted
births were avoided. The gap between wanted and
observed fertility rate is wider among rural women
than among urban women. Within ecological zones,
the gap is widest in the mountains (2.2). Among the
development regions, the gap varies between 1.3 chil-
dren per woman in the Western region and 2.1 chil-
dren per woman in the Mid-western region. The gap
between wanted and observed fertility decreases with
increases in the level of womens education. For ex-
ample, women with no education have 1.8 children
more than their ideal, compared with women with at
least an SLC level of education who have 0.3 children
above their ideal.

An increase in womens status and empower-
ment may lower fertility through a negative associa-
tion with desired family size and a positive associa-
tion with ability to meet family-size goals through the
effective use of contraception. Table 7.9 shows the
mean ideal number of children and the unmet need for
spacing and limiting by the three indicators of
womens status, namely, womens decision-making
participation, womens attitude toward refusing sex
with their husband, and womens attitude toward wife
beating. The mean ideal number of children varies
little by the first two womens status indicators and
varies positively with the third. The data show that
women who are least likely to agree that a man is justified in beating his wife have the lowest mean
ideal family size and vice versa. Unmet need for family planning and especially for spacing de-
creases as womens involvement in household decision-making increases. There is no clear relation-
ship between unmet need for family planning and womens attitude toward refusing sex with their
husband and wife beating.
Table 7.8 Wanted fertility rates
Total wanted fertility rates and total fertility rates for
the three years preceding the survey, by back-
ground characteristics, Nepal 2001


Background
characteristic
Total wanted
fertility rate
Total
fertility rate

Residence

Urban 1.4 2.1
Rural 2.6 4.4

Ecological zone
Mountain 2.6 4.8
Hill 2.3 4.0
Terai 2.6 4.1

Development region
Eastern 2.3 3.8
Central 2.7 4.3
Western 2.2 3.5
Mid-western 2.6 4.7
Far-western 2.9 4.7

Education
No education 3.0 4.8
Primary 2.0 3.2
Some secondary 1.6 2.3
SLC and above 1.8 2.1

Total 2.5 4.1
Note: Rates are calculated based on births to
women age 15-49 in the period 1-36 months pre-
ceding the survey. The total fertility rates are the
same as those presented in Table 4.2.
SLC = School Leaving Certificate


126 * Fertility Preferences

Table 7.9 Ideal number of children and unmet need for family planning by women's status

Mean ideal number of children and unmet need for spacing and limiting, by women's status
indicators, Nepal 2001

Unmet need for
family planning
2


Women's status
indicator
Mean ideal
number of
children
1
Number
For
spacing
For
limiting Total

Number
of
women


Number of decisions in which
woman has final say
3


0 2.5 1,303 23.3 10.5 33.7 1,327
1-2 2.7 3,683 12.1 16.1 28.2 3,761
3-4 2.7 1,888 6.0 15.3 21.3 1,914
5 2.6 1,698 4.1 19.0 23.1 1,725

Number of reasons to refuse
sex with husband

0 2.8 96 8.1 17.0 25.1 102
1-2 2.8 253 15.3 15.5 30.8 261
3-4 2.6 8,223 10.8 15.7 26.4 8,363

Number of reasons wife
beating is justified

0 2.6 6,133 10.0 16.1 26.2 6,216
1-2 2.6 1,885 12.8 15.3 28.1 1,940
3-4 2.9 446 13.9 11.6 25.5 457
5 3.1 109 12.2 12.4 24.6 113

Total 2.6 8,572 10.9 15.7 26.5 8,726

1
Totals are calculated excluding the women giving non-numeric responses.
2
See Table 7.4 for definition of unmet need for family planning
3
Either by herself or jointly with others






Infant and Child Mortality * 127
8
INFANT AND CHILD MORTALITY


This chapter presents information on levels, trends, and differentials in neonatal, postneontal,
infant, and child mortality and on the prevalence of high-risk fertility behavior. This information is
central to an assessment of the demographic situation in Nepal. It is also crucial to the design of
policies and programs targeted at the reduction of infant and child mortality and the avoidance of
high-risk behavior.

Mortality estimates are computed from information collected in the pregnancy history section
of the Womens Questionnaire administered in the 2001 Nepal Demographic and Health Survey
(NDHS). Reproductive histories were obtained from ever-married women. Each woman was first
asked about the number of her own sons and daughters living with her, the number living elsewhere
and the number who had died, and the number of pregnancies that did not end in a live birth. She
was then asked for a history of all her pregnancies, including the type of pregnancy outcome and the
month and year the pregnancy ended. For each pregnancy ending in a live birth, the mother was
asked the childs name, sex, age (if alive) or age at death (if dead), and whether the child was living
with her.

The information on live births is used to directly estimate mortality rates. In this report, in-
fant and child mortality are measured using the following five rates:

Neonatal mortality: the probability of dying within the first month of life
Postneonatal mortality: the difference between infant and neonatal mortality
Infant mortality: the probability of dying before the first birthday
Child mortality: the probability of dying between the first and fifth birthday
Under-five mortality: the probability of dying before the fifth birthday.

All rates are expressed per 1,000 live births, except child mortality, which is expressed per
1,000 children surviving to 12 months of age.

Information on pregnancies that did not end in a live birth and on children who died within
seven days is used to estimate perinatal mortality, which is the number of stillbirths and early neo-
natal deaths per 1,000 stillbirths and live births.

8.1 DATA QUALITY

The reliability of mortality estimates depends on the sampling variability of the estimates and
on nonsampling errors. Sampling errors are presented in Appendix B. Nonsampling errors arise
from data collection problems and, in the case of mortality data, the most common types of problems
are as follows: misreporting of age at death; misreporting of dates of birth and event underreporting
(that is, both the birth and death of the child). The possible occurrence of these data problems in the
2001 NDHS will be discussed with reference to the data quality tables in Appendix C.
128 * Infant and Child Mortality
In the case of misreporting age at death, the most typical problem in survey data is the misre-
porting of infant deaths, which occur in the late postneonatal period, as deaths at 12 months or one
year of age (digit preference in the reporting of age). Such misreporting results in underestimation of
the infant mortality rates and overestimation of child mortality rates. A review of the reported age at
death data (Table C.6) indicates that digit preferences in reported death at 12 months or one year is
not a problem in the 2001 NDHS and that reporting errors did not arise from this source.

Misreporting of the date of birth of deceased children is common in many surveys that in-
clude both demographic and health information for children born since a specified date (that is, for
children below age five). In the 2001 NDHS, the cutoff date for asking health questions was Baisakh
2052 in the Nepali calendar (corresponding to April 1995 in the Gregorian calendar). Table C.4 indi-
cates that there is little misreporting of dates of birth for living children but that there is evidence of
misreporting of dates for deceased children. The evidence for this is the 203 births in calendar year
2051 (1994) but only 128 births in calendar year 2052 (1995). The deficit in calendar year 2052 is
believed to be the result of misreporting of date of birth by interviewers who want to avoid collecting
the health data for deceased children. The transference of deceased children out of the five-year pe-
riod preceding the survey strongly suggests that the estimated infant mortality rate for that period
will be negatively biased and will understate the true level of infant mortality for the period of the
late 1990s.

The problem of underreporting is usually most severe for deaths that occur very early in
infancy. Table C.5 provides data for evaluating the occurrence of underreporting of early infant
deaths. Selective underreporting of early neonatal deaths would result in an abnormally low ratio of
deaths under seven days to all neonatal deaths. In the 2001 NDHS, this ratio is high (between 65 and
69) so that it can be concluded that there has not been selective omission of early infant deaths.
1


While the evidence in Table C.5 does not indicate selective underreporting of early neo-
natal deaths, it is possible that there was a general tendency to underreport deceased children for the
five-year period preceding the survey, the period for which health data are collected for each re-
corded birth. The motivation that interviewers have for omitting these events has already been indi-
cated. The possibility that this occurred must be considered because of the sharp drop in infant and
child mortality rates, a topic that is further discussed in the next section.

8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY

Table 8.1 presents neonatal, postneonatal, infant, child, and under-five mortality rates for the
three five-year periods preceding the survey. Under-five mortality in Nepal is 91 deaths per 1,000
births in the most recent five-year period (0-4 years preceding the survey). This means that about
one in every 11 children born in the country dies before reaching age five. Slightly more than two in
three under-five deaths occur in the first year of lifeinfant mortality is 64 deaths per 1,000 births


1
There are no model mortality patterns for the neonatal period. However, one review of data from several de-
veloping countries concluded that at levels of neonatal mortality of 20 per 1,000 or higher, approximately 70 percent of
neonatal deaths occur within the first six day of life (Boerma, 1988).
Infant and Child Mortality * 129

Table 8.1 Early childhood mortality rates
Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods
preceding the survey, Nepal 2001


Years preceding
the survey
Neonatal
mortality
(NN)
Postneonatal
mortality
(PNN)
1

Infant
mortality
(
1
q
0
)
Child
mortality
(
4
q
1
)
Under-five
mortality
(
5
q
0
)
0-4 38.8 25.6 64.4 28.6 91.2

5-9 56.5 33.5 90.0 39.7 126.2

10-14 63.1 44.0 107.2 57.0 158.0

1
Computed as the difference between the infant and neonatal mortality rates


and child mortality is 29 deaths per 1,000 births. During infancy, the risk of neonatal death (39 per
1,000) is one and half times higher than the risk of postneonatal death (26 per 1,000).

According to data collected in the 2001 NDHS, mortality levels have declined rapidly in Ne-
pal since the early 1980s (Table 8.1). However, as discussed in the earlier section on data quality,
this decline could be overstated due to the misreporting of the dates of birth of deceased children and
the underreporting of deceased children. Under-five mortality in the five years before the survey is
58 percent of what it was 10-14 years before the survey. Comparable data for child mortality (50
percent) and infant mortality (60 percent) indicate that the pace of decline is somewhat faster for
child mortality than for infant mortality. The corresponding figures for neonatal and postneonatal
mortality are 61 percent and 58 percent, respectively.

Mortality trends can also be examined by comparing data from the 2001 NDHS with data
from other earlier sources. However, these comparisons should be interpreted with caution since the
quality of data, method of analysis, time references, and sample coverage varies. Table 8.2 and Fig-
ure 8.1 show direct estimates of infant mortality from various sources. There is some indication that
the infant mortality rate was underestimated in the 1986 and 1991 data, but this does not change the
broad conclusion that there has been a substantial decline in infant mortality over the 30 years pre-
ceding the survey from about 150 in the late 1960s to about half this level in the late 1990s.

Table 8.2 Trends in infant mortality

Trends in the infant mortality rate in Nepal, 1969-1998


Approximate
midpoint
NFS
1976
NFFS
1986
NFHS
1991
NFHS
1996
NDHS
2001

1969 156
1974 140
1979 90 123
1984 103 115 127
1988 80 108 107
1993 79 90
1998 64
Source: Ministry of Health, 1987:80; Ministry of Health, 1993:132;
Pradhan et al., 1997: 102



Infant and Child Mortality * 131
Table 8.3 Early childhood mortality rates by socioeconomic characteristics
Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding
the survey, by socioeconomic characteristic, Nepal 2001


Socioeconomic
characteristic
Neonatal
mortality
(NN)
Postneonatal
mortality
(PNN)
1

Infant
mortality
(
1
q
0
)
Child
mortality
(
4
q
1
)
Under-five
mortality
(
5
q
0
)
Residence

Urban 36.6 13.5 50.1 16.7 65.9
Rural 48.5 30.8 79.3 35.4 111.9

Ecological zone
Mountain 64.9 47.1 112.0 51.2 157.4
Hill 41.9 24.3 66.2 29.7 93.9
Terai 49.7 31.1 80.8 34.8 112.8

Development region
Eastern 50.5 27.0 77.5 29.6 104.8
Central 48.4 29.0 77.4 36.4 110.9
Western 39.1 21.0 60.1 25.1 83.7
Mid-western 40.5 32.3 72.9 41.2 111.0
Far-western 64.4 47.8 112.2 41.7 149.2

Mother's education
No education 51.6 33.0 84.6 39.5 120.7
Primary 41.2 19.8 61.0 13.4 73.5
Some secondary 31.3 18.6 49.9 14.3 63.5
SLC and above (8.8) (2.3) (11.2) (3.7) (14.9)
Note: Rates in parentheses are based on 250-499 exposed children
SLC = School Leaving Certificate

1
Computed as the difference between the infant and neonatal mortality rates



66
157
105
112
94
111
113
84
111
149
Urban Rural Mountain Hill Terai Eastern Central Western Mid-
western
Far-
western
Place of residence
0
20
40
60
80
100
120
140
160
180
Deaths per 1,000 births
Figure 8.2 Under-five Mortality Rates
by Place of Residence
Nepal 2001 Note: Rates are for the 10-year period preceding the survey.


132 * Infant and Child Mortality
8.4 DEMOGRAPHIC DIFFERENTIALS IN MORTALITY

Besides socioeconomic characteristics, demographic characteristics of the child and the
mother have been found to affect mortality risks. Some of these factors are the sex of the child,
mothers age at birth, birth order, length of previous birth interval, and the mothers perception of the
size of the child at birth. The relationship between these demographic characteristics and mortality is
shown in Table 8.4 and Figure 8.3.

As expected, neonatal mortality is higher among males than among females. There is little
variation in postneonatal mortality and infant mortality by sex of the child. However, child mortality
is nearly one and a half times higher for females than for males. Since female mortality is typically
lower than male mortality during childhood, this pattern suggests some gender-related differences in
child-rearing practices and health care utilization.


Table 8.4 Early childhood mortality rates by demographic characteristics
Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding
the survey, by demographic characteristics, Nepal 2001


Demographic
characteristic
Neonatal
mortality
(NN)
Postneonatal
mortality
(PNN)
1

Infant
mortality
(
1
q
0
)
Child
mortality
(
4
q
1
)
Under-five
mortality
(
5
q
0
)
Child's sex

Male 52.0 27.2 79.2 27.8 104.8
Female 43.3 31.9 75.2 40.2 112.4

Mother's age at birth
2

<20 71.2 37.1 108.2 28.5 133.6
20-29 40.3 27.3 67.6 32.6 98.0
30-39 42.8 30.1 72.9 42.5 112.3

Birth order
1 56.8 32.0 88.8 22.9 109.7
2-3 44.1 27.5 71.6 28.6 98.1
4-6 39.7 29.7 69.4 44.8 111.1
7+ 63.0 31.1 94.1 51.1 140.4

Previous birth interval
3

<2 79.9 44.5 124.4 54.8 172.4
2 years 39.7 28.0 67.8 40.0 105.1
3 years 26.5 18.8 45.2 22.4 66.6
4+ years 21.7 17.2 38.9 20.1 58.2

Birth size
4

Small/very small 58.1 32.2 90.3 na na
Average or larger 32.4 24.0 56.4 na na
na = Not applicable
1
Computed as the difference between the infant and neonatal mortality rates
2
Rates for age group 40-49 are not shown because they are based on fewer than 250 exposed chil-
dren.

3
Excludes first-order births
4
Rates for the five-year period before the survey


Infant and Child Mortality * 133
Figure 8.3 Under-Five Mortality by
Selected Demographic Characteristics
Note: Rates are for the 10-year period preceding the survey
134
98
112
172
105
67
58
AGE OF MOTHER
<20
20-29
30-39
BIRTH ORDER
1
2-3
4-6
7+
PRIOR BIRTH INTERVAL
< 2 years
2 years
3 years
4+ years
0 50 100 150 200
Deaths per 1,000 live births
Nepal 2001
110
98
111
140



The relationship between maternal age (at birth) and neonatal, postneonatal, infant, and
under-five mortality shows a U-shaped curve. These mortality measures are substantially higher
among children born to mothers less than 20 or more than 30 years old.

As expected, first births and higher order births experience higher mortality, indicating a U-
shaped relationship between birth order and mortality. For example, infant mortality for first births
and births of order seven and higher is 89 per 1,000 births and 94 per 1,000 births, respectively, com-
pared with about 70 per 1,000 births for second to sixth order births.

Mortality among children is negatively associated with the length of the previous birth inter-
val. Under-five mortality decreases sharply from a high of 172 for children born less than two years
after a previous birth to 58 per 1,000 live births for children born four or more years after a previous
birth.

A childs size at birth has often been found to be an important determinant of the chances of
survival in infancy. Since most births in Nepal take place outside of a health facility, few children
are weighed at birth; as such, in the 2001 NDHS, mothers were asked to assess their childs size at
birth. Even though this is a subjective assessment, it has been shown to closely correlate with actual
birth weight in most countries. Due to small numbers, births have been grouped into small/very
small and average/larger to give statistically reliable estimates. As expected, size of the baby at birth
and mortality are negatively associated. For example, children who were regarded as very small or
small have an infant mortality rate that is 60 percent higher than that for average/large children.
134 * Infant and Child Mortality
8.5 WOMENS STATUS AND CHILD MORTALITY

Since women are the primary caregivers, their status can impact the health status and survival
of their children. Women who are empowered are in a better position to access information, make
decisions, and act effectively to address their own and their childrens health. Table 8.5 shows the
relationship between mortality rates and the three indicators of womens empowerment measured in
the 2001 NDHS. In general, the more decisionmaking power a woman has, the lower the level of
childhood mortality, as observed with four of the five mortality rates (the exception being child mor-
tality). There is no clear relationship between childhood mortality rates and womens attitudes to-
ward a womans right to refuse sex with her husband or toward wife beating.


Table 8.5 Early childhood mortality rates by women's status
Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding
the survey, by women's status indicators, Nepal 2001


Women's status indicators
Neonatal
mortality
(NN)
Postneonatal
mortality
(PNN)
1

Infant
mortality
(
1
q
0
)
Child
mortality
(
4
q
1
)
Under-five
mortality
(
5
q
0
)


Number of decisions in
which woman has final say
2


0 57.2 33.6 90.8 24.8 113.3
1-2 49.7 34.3 84.0 35.1 116.2
3-4 38.8 24.9 63.7 33.9 95.4
5 47.1 21.5 68.6 34.5 100.8

Number of reasons to re-
fuse sex with husband

1-2 49.7 32.9 82.5 (33.2) (113.0)
3-4 47.6 29.6 77.1 34.0 108.5

Number of reasons wife
beating is justified

0 48.9 29.5 78.4 34.5 110.1
1-2 41.7 28.4 70.1 36.4 103.9
3-4 54.5 35.1 89.7 16.1 104.3
Note: Rates in parentheses are based on 250-499 exposed children. Rates for 0 reasons to refuse sex
with husband and 5 reasons wife beating is justified are not shown because they are based on fewer
than 250 exposed children.
1
Computed as the difference between the infant and neonatal mortality rates
2
Either by herself or jointly with others



8.6 PERINATAL MORTALITY

Perinatal mortality reflects an adverse outcome for pregnancies of at least seven months ges-
tation. The perinatal mortality rate is obtained by summing all stillbirths and deaths to children
within the first week of life (early neonatal deaths) and dividing by the sum of all stillbirths and live
births. The perinatal mortality rate captures stillbirths and early neonatal deaths, two seemingly dif-
ferent outcomes that result from similar conditions.
Infant and Child Mortality * 135



In the 2001 NDHS, women were asked to report on all the pregnancies that they had in their
lifetime. The pregnancy history provides information on all the respondents children born alive or
dead, whether or not still living, and all the pregnancies that did not end in a live birth.

Information on perinatal mortality is obtained from reports of pregnancy losses and preg-
nancy duration (which defines stillbirths) and deaths to children within the first week of life. These
events are highly susceptible to omission and misreporting. Nevertheless, retrospective surveys pro-
vide more representative and complete enumeration of perinatal deaths than most vital registration
systems and hospital-based studies in developing countries.

Data obtained from this survey have been summarized in Table 8.6. The perinatal mortal-
ity rate for the five years prior to the survey is 47 deaths per 1,000 pregnancies, a decline from 61
deaths in the ten years preceding the 1996 NFHS.

As expected, mothers age has a U-shaped relationship with perinatal mortality. For ex-
ample, perinatal mortality is higher among women in the youngest and oldest age groups. Perinatal
mortality is about twice as high if the length of the previous birth interval is shorter than 15 months
than if the birth interval is 15 months or longer.

Perinatal mortality is lower in urban areas than in rural areas and among mothers living in
the hill region than among those living in the mountains or terai. Perinatal mortality is also lowest in
the Western development region. There is an inverse relationship between perinatal mortality and
mothers education.
136 * Infant and Child Mortality

Table 8.6 Perinatal mortality
Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for
the five-year period preceding the survey, by background characteristics, Nepal
2001


Background
characteristic
Number of
stillbirths
1

Number of
early neonatal
deaths
2

Perinatal
mortality
rate
3

Number of
pregnancies
of 7+
months
duration

Mother's age at birth

<20 32 61 69.9 1,322
20-29 86 80 39.5 4,194
30-39 33 31 44.7 1,425
40-49 5 11 82.7 193

Previous pregnancy
interval in months

<15 16 22 109.7 351
15-26 42 39 45.0 1,804
27-38 27 35 34.9 1,781
39+ 71 85 48.8 3,198

Residence
Urban 8 8 36.6 458
Rural 148 173 48.1 6,676

Ecological zone
Mountain 19 18 66.1 554
Hill 66 59 42.4 2,939
Terai 72 105 48.6 3,641

Development region
Eastern 39 53 55.7 1,649
Central 52 58 46.5 2,362
Western 20 27 37.0 1,282
Mid-western 28 17 41.9 1,076
Far-western 17 27 57.1 766

Mother's education
No education 125 142 50.2 5,301
Primary 21 24 45.1 991
Some secondary 10 17 45.1 597
SLC and above 0 0 0.0 244

Total 156 182 47.4 7,134
SLC = School Leaving Certificate

1
A still birth is a fetal death that occurs in a pregnancy lasting seven or more
months.
2
An early neonatal death is the death of a live-born child at age 0 to 6 days.
3
The perinatal mortality rate is the sum of the number of stillbirths and early neona-
tal deaths divided by the number of pregnancies of seven or more months duration.


8.7 HIGH-RISK FERTILITY BEHAVIOR

Research has shown that there is a strong relationship between certain characteristics associ-
ated with fertility behavior and childrens survival chances. Typically, the probability of dying in
infancy is much greater for children born to mothers who are too young or too old, children born af-
ter a short birth interval, and children born to mothers with high parity. For analysis purposes, a
mother is classified as too young if she is less than 18 years old and too old if she is over 34 at
the time of delivery. A short birth interval is defined as a birth occurring less than 24 months after
the previous birth, and a mother is of high parity if she has given birth to three or more living chil-
dren, that is, if the child is of birth order four or higher.

Infant and Child Mortality * 137
Table 8.7 shows the percent
distribution of children born in the five
years preceding the survey and of cur-
rently married women by these risk
factors. The table also displays the
risk ratio of mortality for children by
comparing the proportion of deceased
children in each high-risk category
with the proportion of deceased chil-
dren not in any high-risk category.

Fifty-three percent of Nepalese
children born in the five years preced-
ing the survey fall into a high-risk
category, with 37 percent in a single
high-risk category and 16 percent in a
multiple high-risk category. Three in
ten births in Nepal are not in any risk
category, and 18 percent are in an un-
avoidable risk category (first order
births to women age 18-34).

The relationship between risk
factors and mortality is given by the
risk ratios displayed in column 2 of
Table 8.7. In general, risk ratios are
higher for children in a multiple high-
risk category than in a single high-risk
category. The most vulnerable births
are those to women who are age 35 or
older, with a birth interval less than 24
months and birth order three or higher.
These children are nearly 2.4 times
more likely to die than children not in
any high-risk category. Fortunately,
only 1 percent of births are in this cate-
gory. It is also worthwhile to note that
7 percent of births occur to mothers
who have three or more children and a
short previous birth interval. These
children are more than twice as likely
to die as children who are not in any
high-risk category. Another 7 percent
of births occur to women under age 18;
these babies are also subject to twice
the risk of dying than children who are
not in any high-risk category.
Table 8.7 High-risk fertility behavior
Percent distribution of children born in the five years preceding the
survey by category of elevated risk of mortality, risk ratio, and per-
cent distribution of currently married women by category of risk if
they were to conceive a child at the time of the survey, Nepal 2001


Births in the 5 years
preceding the survey

Risk category
Percentage
of births Risk ratio

Percentage
of currently
married
women
1

Not in any high-risk category
29.8 1.00 32.3
a



Unavoidable risk category
First order births between
age 18 and 34 years 17.5 1.30 8.3


Single high-risk category
Mother's age <18 6.6 2.24 2.3
Mother's age >34 0.4 1.62 2.9
Birth interval <24 months 9.1 1.34 8.9
Birth order >3 20.5 1.17 13.3

Subtotal 36.6 1.41 27.4

Multiple high-risk category
Age <18 & birth interval
<24 months
2
0.4 2.01 0.3

Age >34 & birth interval
<24 months 0.0 0.00 0.1

Age >34 & birth order >3 7.8 1.08 21.4
Age >34 & birth interval
<24 months & birth order >3 1.0 2.38 2.3

Birth interval <24 months
& birth order >3 6.8 2.18 7.9


Subtotal 16.1 1.65 32.1

In any avoidable high-risk
category 52.7 1.48 59.4


Total 100.0 na 100.0
Number of births 6,978 na 8,342
Note: Risk ratio is the ratio of the proportion dead among births in
a specific high-risk category to the proportion dead among births
not in any high-risk category.
na = Not applicable
1
Women are assigned to risk categories according to the status they
would have at the birth of a child if they were to conceive at the
time of the survey: current age less than 17 years and 3 months or
older than 34 years and 2 months, latest birth less than 15 months
ago, or latest birth being of order 3 or higher.
2
Includes the category age <18 and birth order >3
a
Includes sterilized women

138 * Infant and Child Mortality




The final column of Table 8.7 addresses the question of what percentage of currently married
women have the potential for having a high-risk birth. This was obtained by simulating the distribu-
tion of currently married women by the risk category in which a birth would fall if a woman were to
conceive at the time of the survey.

Overall, 59 percent of currently married women have the potential to give birth to a child
with an elevated risk of mortality. Twenty-one percent of these women are or would be too old and
have or would have too many children. A slightly higher proportion of women exhibit the potential
for having a birth in a multiple high-risk category than in a single high-risk category.


Maternal and Child Health * 139
9
MATERNAL AND CHILD HEALTH


The Safe Motherhood Program in Nepal has adopted two major strategies to improve mater-
nal healthprovide around-the-clock essential obstetric services and ensure the presence of skilled
attendants at deliveries, especially at-home deliveries (Ministry of Health, 2001). In recognizing that
the majority of women do not have access to maternal health care services due to social, economic,
and political reasons, the Ministry of Health is emphasizing a multisectoral approach that encom-
passes medical interventions and nonhealth programs that promote access to and utilization of ser-
vices. Based on the National Health Policy, the Safe Motherhood National Plan of Action (1994-
1997) was developed. Ten districts were initially selected for the program, and in the first phase, the
program was launched in three districts. After the evaluation of the first phase, six more districts
were incorporated in the second phase by 2001. In conjunction with the Ministry of Healths efforts,
several other programs to support safe motherhood have been initiated by international organizations
like the World Health Organization (WHO), the United Nations Childrens Fund (UNICEF), the
United Nations Population Fund (UNFPA), the Department for International Development (DFID),
U.S. Agency for International Development (USAID), and German Agency for Technical Coopera-
tion (GTZ) in several targeted districts. These include the promotion of maternal health programs
through the construction of maternity facilities, human resource development, and the provision of
essential obstetric care kits and maternal and child health equipment to primary health centers and
hospitals. USAID supports the Safe Motherhood Program with the maternal and child health work-
ers (MCHWs) refresher training curriculum, the National Safe Motherhood Subcommittee and regu-
lar newsletter, the National Safe Motherhood IEC strategy, postabortion care training as part of
emergency obstetric care, and the Birth Preparedness Package for families to plan for normal births
and emergencies.

This chapter presents the survey findings in four areas of importance to maternal and child
health: antenatal, delivery, and postnatal services; characteristics of the newborn; vaccination cover-
age; and common childhood illnesses and their treatment. Combined with information on maternal
and childhood mortality, this information can be used to identify subgroups of women and children
who are at risk because of low levels of use or nonuse of maternal and child health services and to
provide information to assist in the planning of appropriate improvements in services.

9.1 ANTENATAL CARE
ANTENATAL CARE COVERAGE

The maternal health care services that a mother receives during her pregnancy and at the time
of delivery is important for the well being of the mother and her child. Antenatal care (ANC) can be
assessed according to the type of service provider, number of visits made, the stage of pregnancy at
the time of first visit, services and information provided during ANC checkups (including whether
tetanus toxoid vaccinations were received). Information on ANC coverage was collected from
women who had a live birth in the five years preceding the survey. For women with two or more live
births during the five-year period, the data refer to the most recent birth only.

Table 9.1 and Figure 9.1 show the percent distribution of mothers who had a live birth in the
five years preceding the survey by source of antenatal care received during pregnancy according to


140 * Maternal and Child Health
Table 9.1 Antenatal care
Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC) provider
during pregnancy for the most recent birth, according to background characteristics, Nepal 2001


Background
characteristic Doctor
Nurse/
auxiliary
nurse
midwife
Health
assistant/
auxiliary
health
worker
Maternal
child
health
worker
Village
health
worker
Traditional
birth
attendant/
other No one Total
Number
of
women

Age
<20 21.5 13.4 13.8 4.4 5.8 0.4 40.7 100.0 773
20-34 17.2 11.7 10.8 3.2 6.7 0.6 49.8 100.0 3,419
35-49 6.5 5.7 8.6 2.5 4.7 0.4 71.6 100.0 553

Birth order
1 27.4 14.8 13.6 4.0 4.8 0.4 35.0 100.0 993
2-3 18.5 13.6 11.7 3.9 6.9 0.5 44.9 100.0 1,900
4-5 11.3 8.3 9.4 2.0 6.0 0.9 62.1 100.0 1,107
6+ 5.4 5.3 8.2 3.0 7.5 0.2 70.4 100.0 746

Residence
Urban 54.5 20.2 4.3 0.8 1.1 1.3 17.6 100.0 332
Rural 13.8 10.6 11.5 3.5 6.7 0.5 53.4 100.0 4,414

Ecological zone
Mountain 5.5 7.0 13.8 3.0 1.2 0.1 69.3 100.0 361
Hill 15.8 10.3 10.4 4.6 2.8 0.1 56.0 100.0 1,979
Terai 19.0 12.8 11.1 2.2 10.1 1.0 43.9 100.0 2,405

Development region
Eastern 17.1 17.0 15.4 1.7 2.0 1.2 45.7 100.0 1,102
Central 18.6 7.8 10.1 2.3 13.2 0.6 47.4 100.0 1,535
Western 22.9 12.7 12.1 6.1 2.8 0.0 43.5 100.0 914
Mid-western 7.1 8.4 8.4 5.2 5.5 0.3 64.9 100.0 693
Far-western 11.1 11.0 5.8 2.2 2.6 0.2 67.0 100.0 502

Subregion
Eastern Mountain 8.3 7.3 21.8 3.1 1.6 0.0 58.0 100.0 74
Central Mountain 5.7 12.2 18.7 5.2 2.2 0.4 55.7 100.0 122
Western Mountain 4.2 3.1 6.6 1.4 0.3 0.0 84.3 100.0 166
Eastern Hill 12.7 17.1 13.0 3.2 3.8 0.0 50.2 100.0 347
Central Hill 22.7 12.7 11.3 2.0 3.1 0.2 48.0 100.0 484
Western Hill 24.2 11.8 13.1 8.1 1.8 0.0 41.0 100.0 521
Mid-western Hill 3.8 3.6 6.2 5.8 3.3 0.4 77.0 100.0 405
Far-western Hill 7.9 2.8 5.4 2.5 1.7 0.0 79.6 100.0 223
Eastern Terai 20.3 18.0 15.9 0.7 1.1 1.9 42.1 100.0 681
Central Terai 18.1 4.7 8.3 2.1 19.9 0.9 46.0 100.0 930
Western Terai 21.2 13.9 10.7 3.3 4.1 0.0 46.8 100.0 393
Mid-western Terai 14.8 18.7 15.0 5.2 11.2 0.2 34.8 100.0 222
Far-western Terai 18.2 25.8 3.5 2.3 4.7 0.6 44.5 100.0 179

Education
No education 9.5 8.7 10.7 2.9 6.9 0.5 60.8 100.0 3,437
Primary 22.3 17.7 12.1 4.6 7.0 0.5 35.5 100.0 684
Some secondary 42.8 20.4 11.9 4.5 3.1 1.2 16.0 100.0 439
SLC and above 65.8 14.9 10.1 3.1 0.9 0.0 5.2 100.0 186

Total 16.6 11.3 11.0 3.3 6.3 0.5 50.9 100.0 4,745
Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this
tabulation. Total includes women with missing information on antenatal care provider who are not shown separately.
SLC = School Leaving Certificate



Maternal and Child Health * 141
selected background characteristics. Interviewers were instructed to record all persons a woman had
seen for antenatal care for the most recent birth. But in the table, only the provider with the highest
qualifications is listed if the woman had seen more than one provider.

Overall, one in two pregnant women received antenatal care. Twenty-eight percent of moth-
ers received antenatal care either from a doctor (17 percent) or a nurse or auxiliary nurse midwife (11
percent). Another 11 percent of mothers received antenatal care from a health assistant (HA) or aux-
iliary health worker (AHW). Village health workers (VHWs) provided antenatal care to 6 percent of
women and maternal and child health workers (MCHWs) provided care to 3 percent of mothers.
Traditional birth attendants (TBAs) provided antenatal care to less than 1 percent of mothers.

49
51
45
9
45
9
89
13
23
55
9
ANTENATAL CARE
Health professional
No one
TT VACCINATION
None
One
2+
PLACE OF DELIVERY
Health facility
Home
DELIVERY ASSISTANCE
Health professional
TBA
Relative/friend/other
No one
0 20 40 60 80 100
Percent
Nepal 2001
Figure 9.1 Antenatal Care, Tetanus Toxoid (TT) Vaccinations,
Place of Delivery, and Delivery Assistance
Note: Health professional refers to doctor, nurse/auxiliary nurse midwife, health
assistant/auxiliary health worker, maternal child health worker, village health worker.
TBA = Traditional birth attendant


Comparison with the 1996 Nepal Family Health Survey results shows that there were some
improvements in the utilization of antenatal services during the last five years. The percentage of
women receiving antenatal services from a doctor, nurse, or auxiliary nurse midwife (ANM) has in-
creased from 24 percent in 1996 to 28 percent in 2001. At the same time, the percentage of mothers
receiving antenatal care from a HA or AHW increased from 2 percent to 11 percent. The percentage
of mothers who did not receive any antenatal care dropped from 56 percent to 51 percent over the
same period.

Younger women are more likely to use antenatal services than older women. This is espe-
cially true for care from doctors, nurses or ANMs and HAs or AHWs. Similarly, lower birth order is
associated with greater use of antenatal services provided by medically trained personnel. Perhaps
this pattern occurs because young women tend to be more educated than older women and are thus
more likely to know that antenatal care from medically trained personnel is superior in quality. Also
older women who have given birth previously may feel less need for ANC services. There are large
differences in the use of antenatal care services between urban and rural women. Overall, 82 percent
of women from urban areas utilize antenatal care services, compared with 47 percent of their rural


142 * Maternal and Child Health


counterparts. Urban women use doctors and nurses or ANMs much more often than rural women,
whereas rural women are more likely to use HAs or AHWs and MCHWs for antenatal care.

Utilization of antenatal care services is higher in the terai and in the Western, Eastern, and
Central development regions than in the other regions. Similarly, women from the terai subregions
and Western and Central hills use ANC services more often and from doctors and nurses or ANMs
than in other areas. Women from the Western mountains are least likely to obtain ANC services,
while women from the Mid-western terai are most likely to use ANC services. Reported use of doc-
tors for antenatal care should be viewed with caution because in most rural areas, nurses and para-
medical personnel are regarded as doctors and health posts and subhealth posts are regarded as hos-
pitals.

The utilization of antenatal care services
is positively associated with mothers level of
education. Ninety-five percent of women with
an SLC and above received antenatal care ser-
vices, compared with 39 percent of women with
no education. Use of a doctor for antenatal care
increases from 10 percent among uneducated
women to 66 percent among women who have
completed their SLC.

Antenatal care can be more effective in
avoiding adverse pregnancy outcomes when it is
sought early in the pregnancy and continues
through to delivery. The National Safe Mother-
hood Program guidelines in Nepal recommend
at least four visits during pregnancy. The first
visit should be made soon after the woman real-
izes she is pregnant. The second visit should be
made between the fifth and the seventh month
of pregnancy. The third visit should be made at
the beginning of the ninth month, and the last
visit should be made the same week that the
baby is due. Additional visits should be made if
any problems or danger signs arise.

Table 9.2 indicates that most Nepalese
women who receive antenatal care get it at a
relatively late stage in their pregnancy and do
not make the minimum recommended number
of antenatal visits. Only one in seven (14 per-
cent) women make four or more visits during
their entire pregnancy. Urban women are four times more likely than rural women to have made
four or more ANC visits. Sixteen percent of women reported that their first visit occurred at less
than four months of pregnancy. Forty-one percent of urban women, compared with 15 percent of
rural women, made their first antenatal visit when they were less than four months pregnant. Among
women who received antenatal care, the median duration of pregnancy at first visit was five months.
Table 9.2 Number of antenatal care visits and timing of
first visit

Percent distribution of women who had a live birth in
the five years preceding the survey by number of antena-
tal care (ANC) visits for the most recent birth, and by the
timing of the first visit according to residence, Nepal
2001


Residence


Number and timing of
ANC visits Urban Rural

Total

Number of ANC visits

None 17.6 53.4 50.9
1 6.5 7.9 7.8
2-3 27.3 26.8 26.8
4+ 48.4 11.8 14.3
Don't know/missing 0.3 0.2 0.2

Total 100.0 100.0 100.0

Number of months pregnant
at time of first ANC visit

No antenatal care 17.6 53.4 50.9
<4 41.0 14.6 16.4
4-5 24.3 18.2 18.7
6-7 14.4 10.7 11.0
8+ 2.2 2.9 2.8
Don't know/missing 0.5 0.2 0.2

Total 100.0 100.0 100.0

Median months pregnant at
first visit (for those with ANC) 4.0 5.1 5.0


Number of women 332 4,414 4,745
Maternal and Child Health * 143
CARE COMPONENTS

Pregnancy complications are an important cause of maternal and child morbidity and mortal-
ity. Thus, providing adequate and proper information to expectant mothers about the danger signs
associated with pregnancy and the appropriate action to be taken is an essential component of
antenatal care.

Table 9.3 shows the components of antenatal care among women who received antenatal care
for the most recent birth in the five years preceding the survey. About one in two mothers who re-
ceived antenatal care reported that they were informed about the danger signs of pregnancy compli-
cations or had their weight measured, while one in seven had their height measured as a part of their
ANC checkup. Among various services that a woman receives during her antenatal checkup, meas-
urement of blood pressure is important. It is encouraging to note that three in five women reported
that their blood pressure was measured. Urine tests and blood tests were each done for about three in
ten women who received antenatal care. The relatively low coverage for these two tests may indi-
cate a lack of testing facilities in most of the health institutions.

About one in four women with a live birth in the five years preceding the survey reported that
they received iron/folic acid tablets.

Younger women and low parity women are more likely to receive information about preg-
nancy complications and other components of antenatal care services than older and high parity
women. A similar pattern is observed by urban-rural residence, with urban women more likely than
rural women to receive the various components of antenatal care. In terms of ecological region, a
higher percentage of mothers from the mountain region received information on signs of complica-
tions than mothers from the other ecological regions. In general, a higher percentage of women resid-
ing in the hill ecological zone received the various components of antenatal care.

The different components of antenatal care received varies with womens level of education,
with educated women much more likely to have received all components of antenatal care than un-
educated women. For example, twice as many women with an SLC and above received information
about pregnancy complications than women with no education.
144 * Maternal and Child Health

Table 9.3 Components of antenatal care
Percentage of women with a live birth in the five years preceding the survey who received antenatal care for the most recent
birth, by content of antenatal care, and percentage of women with a live birth in the five years preceding the survey who re-
ceived iron/folic acid tablets for the most recent birth, by background characteristics, Nepal 2001


Among women who received antenatal care


Background
characteristic
Informed of
signs of
pregnancy
complica-
tions
Weight
measured
Height
measured
Blood
pressure
measured
Urine
sample
taken
Blood
sample
taken
Number
of
women
Received
iron/
folic acid
tablets
Number
of
women

Age at birth
<20 49.9 50.1 15.1 65.4 30.9 31.6 458 29.5 773
20-34 47.9 47.7 14.3 59.1 29.5 27.6 1,715 23.0 3,419
35-49 37.9 30.1 7.4 51.9 20.9 16.1 157 11.4 553

Birth order
1 55.9 55.0 16.4 71.7 38.5 38.2 645 36.8 993
2-3 46.8 49.4 15.0 59.3 30.3 28.6 1,045 25.1 1,900
4-5 44.1 39.0 11.6 51.8 19.9 16.5 420 15.0 1,107
6+ 34.2 27.4 6.6 43.3 13.9 12.9 221 9.3 746

Residence
Urban 58.6 79.1 27.3 84.9 59.3 58.1 273 50.7 332
Rural 46.2 42.8 12.2 56.5 25.2 23.6 2,058 20.6 4,414

Ecological zone
Mountain 55.7 38.9 4.5 47.0 18.1 13.9 111 14.1 361
Hill 51.4 52.7 14.3 67.1 33.4 30.3 870 22.1 1,979
Terai 44.6 44.0 14.5 56.2 27.3 27.0 1,350 24.5 2,405

Development region
Eastern 39.3 51.5 13.8 57.2 23.3 23.1 599 24.0 1,102
Central 46.9 42.7 14.8 54.8 33.2 31.7 807 24.8 1,535
Western 54.0 56.1 15.5 71.7 38.4 35.8 517 28.5 914
Mid-western 47.4 26.9 9.1 56.7 17.7 15.5 243 11.3 693
Far-western 61.9 52.5 13.0 61.9 18.7 16.0 165 18.4 502

Subregion
Eastern Mountain 40.7 38.3 8.6 48.1 17.3 14.8 31 16.6 74
Central Mountain 68.6 44.1 0.0 52.9 18.6 14.7 54 22.2 122
Western Mountain 46.7 28.9 8.9 33.3 17.8 11.1 26 7.0 166
Eastern Hill 31.8 36.9 8.3 43.9 15.3 14.0 173 19.7 347
Central Hill 59.3 67.8 25.2 72.6 47.8 47.0 251 28.1 484
Western Hill 50.2 57.9 12.8 75.3 40.7 34.3 307 30.9 521
Mid-western Hill 61.1 17.5 6.1 63.6 12.5 10.7 93 9.1 405
Far-western Hill 69.4 67.1 4.6 77.3 16.2 12.5 45 15.6 223
Eastern Terai 42.5 59.0 16.6 63.8 27.2 27.7 395 27.1 681
Central Terai 38.3 30.1 11.1 46.0 27.5 25.9 502 23.5 930
Western Terai 59.5 53.6 19.5 66.4 35.0 38.1 209 25.3 393
Mid-western Terai 37.7 32.7 10.9 52.0 21.2 19.1 145 17.6 222
Far-western Terai 63.0 51.2 17.9 62.3 19.8 18.1 99 27.1 179

Education
No education 39.4 35.3 10.0 50.5 19.7 18.4 1,346 15.1 3,437
Primary 50.7 51.9 16.4 66.1 28.5 27.7 440 29.4 684
Some secondary 59.5 66.6 21.3 74.0 47.9 45.2 368 50.7 439
SLC and above 77.9 83.2 22.4 86.3 64.1 61.4 176 72.5 186

Total 47.6 47.0 14.0 59.9 29.2 27.6 2,330 22.7 4,745
SLC = School Leaving Certificate

Maternal and Child Health * 145

TETANUS TOXOID COVERAGE

Tetanus toxoid injection, an important component of antenatal care, is given during preg-
nancy primarily for the prevention of neonatal tetanus. Neonatal tetanus is one of the major causes
of infant deaths in Nepal. For full protection, it is recommended that a pregnant woman should re-
ceive at least two doses of tetanus toxoid during her first pregnancy, administered one month apart,
and a booster shot during each subsequent pregnancy. Five doses of tetanus toxoid injections are
considered to provide lifetime protection. However, if a pregnant woman does not have a card show-
ing that she has received previous doses (as is often the case), she is likely to be given two doses, one
month apart, for each pregnancy to ensure adequate protection.

Table 9.4 presents data on tetanus toxoid coverage during pregnancy for women who had a
live birth in the five years preceding the survey by selected background characteristics. Forty-five
percent of women received two or more doses of tetanus toxoid injections during their pregnancy,
and 9 percent received only one dose. Nearly one in two women did not receive any tetanus toxoid
injection during her pregnancy.

Mothers giving birth at a younger age and having lower birth order children are more likely
to receive tetanus toxoid injections than older mothers and those with higher birth order children.
For example, two-thirds of mothers below age 20 received one or more doses of tetanus toxoid injec-
tions, compared with one-third of mothers age 35-49. These patterns make sense since older, higher
parity mothers most likely received tetanus toxoid injections during previous pregnancies. A larger
difference is observed in coverage of tetanus toxoid shots among urban women than among rural
women (81 percent versus 53 percent). A large difference in tetanus toxoid coverage is also ob-
served by ecological zone. Mothers from the terai have the highest tetanus toxoid coverage (67 per-
cent) compared with the hill and mountain zones (44 percent and 29 percent, respectively). In terms
of development region, the Eastern, Central, and Western regions have higher tetanus toxoid cover-
age than the Mid-western and Far-western regions (about 60 percent versus 40 percent, respectively).
Tetanus toxoid coverage is highest in the Eastern terai subregion and lowest in the Western moun-
tain subregion.

Education of mothers is strongly associated with tetanus toxoid coverage. Pregnant mothers
with an SLC and above are twice as likely as mothers with no education to receive at least one dose
of tetanus toxoid injections (95 percent and 47 percent, respectively).
146 * Maternal and Child Health

Table 9.4 Tetanus toxoid injections
Percent distribution of women who had a live birth in the five years preceding the survey by
number of tetanus toxoid injections received during pregnancy for the most recent birth, accord-
ing to background characteristics, Nepal 2001


Background
characteristic None
One
injection
Two
or more
injections
Don't
know/
missing Total
Number
of
women

Age at birth
<20 34.2 10.0 55.7 0.1 100.0 773
20-34 44.1 9.4 46.3 0.2 100.0 3,419
35-49 67.9 7.6 24.5 0.0 100.0 553

Birth order
1 31.5 10.0 58.5 0.0 100.0 993
2-3 39.1 9.8 50.9 0.2 100.0 1,900
4-5 53.7 8.8 37.3 0.2 100.0 1,107
6+ 66.4 7.9 25.5 0.1 100.0 746

Residence
Urban 18.3 13.9 67.3 0.5 100.0 332
Rural 47.3 9.0 43.7 0.1 100.0 4,414

Ecological zone
Mountain 71.1 7.6 21.3 0.0 100.0 361
Hill 55.8 9.1 34.9 0.1 100.0 1,979
Terai 32.7 9.7 57.4 0.2 100.0 2,405

Development region
Eastern 37.4 9.0 53.6 0.0 100.0 1,102
Central 38.7 10.9 50.1 0.4 100.0 1,535
Western 44.1 11.7 44.1 0.1 100.0 914
Mid-western 60.4 5.3 34.3 0.0 100.0 693
Far-western 63.7 6.4 29.9 0.1 100.0 502

Subregion
Eastern Mountain 62.2 8.3 29.5 0.0 100.0 74
Central Mountain 61.7 10.0 28.3 0.0 100.0 122
Western Mountain 81.9 5.6 12.5 0.0 100.0 166
Eastern Hill 50.8 9.8 39.4 0.0 100.0 347
Central Hill 46.8 9.5 43.2 0.6 100.0 484
Western Hill 45.9 13.6 40.4 0.0 100.0 521
Mid-western Hill 70.4 4.6 25.0 0.0 100.0 405
Far-western Hill 79.4 5.1 15.5 0.0 100.0 223
Eastern Terai 27.9 8.7 63.5 0.0 100.0 681
Central Terai 31.5 11.7 56.5 0.3 100.0 930
Western Terai 41.7 9.0 49.1 0.3 100.0 393
Mid-western Terai 35.0 6.7 58.2 0.0 100.0 222
Far-western Terai 34.8 8.0 56.8 0.3 100.0 179

Education
No education 53.0 7.8 39.0 0.2 100.0 3,437
Primary 34.6 12.4 52.8 0.2 100.0 684
Some secondary 18.2 14.1 67.7 0.0 100.0 439
SLC and above 4.6 14.2 81.1 0.0 100.0 186

Total 45.2 9.3 45.3 0.2 100.0 4,745
SLC = School Leaving Certificate

Maternal and Child Health * 147


9.2 DELIVERY CARE

The objective of providing safe delivery services is to protect the life and health of the mother
and her child by ensuring the delivery of a baby safely. An important component of efforts to reduce
the health risk to mothers and children is to increase the proportion of babies delivered under the su-
pervision of health professionals. Proper medical attention under hygienic conditions during delivery
can reduce the risk of complications and infections that may cause death or serious illness either to
the mother or the baby or both. The National Safe Motherhood Program encourages women to de-
liver at facilities under the care of skilled attendants when it is feasible and ensures that facilities are
upgraded and providers are trained to manage complications. Respondents in the 2001 NDHS were
asked to provide information on the place of birth of all children born in the five years preceding the
survey.
PLACE OF DELIVERY

Traditionally, Nepalese children are delivered at home either without assistance or with the
assistance of TBAs or relatives and friends. At the national level, only 9 percent of births are deliv-
ered in health facilities, compared with 89 percent at home (Table 9.5). This is a slight improvement
since 1996, when 8 percent of births were delivered in health facilities. This suggests that despite an
increase in the number of health facilities offering delivery services, use of health facilities during
deliveries is still minimal among most Nepalese women.

Table 9.5 also shows that births to young women and low parity births are more likely to be
delivered at health facilities than births to older women and high parity births. A child born in an ur-
ban area is six times more likely (45 percent) to be delivered at a health facility than a child from a
rural area (7 percent). Children living in the mountain ecological zone are less likely to be delivered
in a health facility than children living in the hill and terai zones.

Use of a health facility for delivery increases sharply with maternal education from 4 percent
of births among women with no education to 55 percent among children of women with an SLC or
higher level of education.

Institutional deliveries are about five times more common among births to mothers who had
four or more antenatal checkups (40 percent) than among births to mothers who had one to three an-
tenatal checkups (8 percent). Institutional deliveries are least prevalent (2 percent) among births to
mothers who did not receive any antenatal checkups. Several factors are likely to contribute to this
positive relationship between antenatal checkups and institutional deliveries. Women who have had
contact with health facilities during pregnancy are more likely to subsequently deliver in an institu-
tion because of the advice and encouragement from health personnel. Women with pregnancy com-
plications are more likely than other women to go for antenatal checkups and deliver in a health fa-
cility because they are more aware of the health risks associated with a complicated pregnancy.
Women, especially the young, urban, and educated, with knowledge of the benefits of modern medi-
cal care will choose to use both antenatal and delivery services.
148 * Maternal and Child Health

Table 9.5 Place of delivery
Percent distribution of live births in the five years preceding the survey by place of delivery, according
to background characteristics, Nepal 2001



Health facility



Background
characteristic
Govern-
ment
sector
Non-
gov.
(NGO)
sector
Private
medical
sector Home Other Missing Total
Number
of
births

Mothers age at birth
<20 9.2 1.5 1.4 85.9 1.8 0.2 100.0 1,290
20-34 6.9 0.9 1.1 89.1 1.9 0.1 100.0 5,043
35-49 3.1 0.2 0.3 93.0 3.5 0.0 100.0 645

Birth order
1 14.5 2.2 2.4 78.6 2.1 0.2 100.0 1,665
2-3 6.1 0.8 1.1 90.2 1.6 0.1 100.0 2,790
4-5 3.3 0.3 0.2 93.8 2.4 0.0 100.0 1,534
6+ 2.3 0.2 0.3 94.8 2.4 0.0 100.0 990

Residence
Urban 34.9 5.7 3.9 53.8 1.4 0.2 100.0 449
Rural 5.1 0.6 0.9 91.3 2.0 0.1 100.0 6,529

Ecological zone
Mountain 3.2 0.0 0.1 93.8 2.9 0.1 100.0 535
Hill 7.2 1.4 1.0 87.8 2.5 0.1 100.0 2,873
Terai 7.4 0.8 1.3 89.0 1.4 0.1 100.0 3,570

Development region
Eastern 7.5 1.4 0.8 89.7 0.5 0.1 100.0 1,610
Central 9.0 1.3 1.4 86.2 2.0 0.1 100.0 2,310
Western 7.2 0.9 1.3 86.9 3.5 0.1 100.0 1,261
Mid-western 2.8 0.0 1.0 93.3 2.9 0.0 100.0 1,048
Far-western 5.2 0.5 0.5 92.3 1.2 0.3 100.0 749

Subregion
Eastern Mountain 5.7 0.0 0.4 94.0 0.0 0.0 100.0 107
Central Mountain 3.9 0.0 0.0 88.1 7.8 0.3 100.0 177
Western Mountain 1.6 0.0 0.0 97.7 0.7 0.0 100.0 251
Eastern Hill 4.5 0.2 0.0 94.4 0.8 0.0 100.0 533
Central Hill 14.1 3.4 1.7 79.5 1.2 0.1 100.0 692
Western Hill 9.5 1.7 1.9 82.5 4.1 0.2 100.0 683
Mid-western Hill 1.7 0.0 0.8 93.1 4.5 0.0 100.0 634
Far-western Hill 2.6 1.1 0.0 95.3 1.0 0.0 100.0 330
Eastern Terai 9.3 2.2 1.4 86.7 0.4 0.1 100.0 969
Central Terai 7.2 0.4 1.5 89.2 1.7 0.0 100.0 1,441
Western Terai 4.5 0.0 0.5 92.1 2.8 0.0 100.0 578
Mid-western Terai 5.8 0.0 1.7 92.0 0.5 0.0 100.0 318
Far-western Terai 10.1 0.0 1.3 85.9 1.9 0.8 100.0 264

Mothers education
No education 3.5 0.2 0.5 93.8 1.9 0.1 100.0 5,176
Primary 9.9 1.0 1.1 85.9 2.1 0.1 100.0 970
Some secondary 20.4 4.8 2.5 69.7 2.3 0.2 100.0 587
SLC and above 37.1 7.5 10.6 42.8 2.0 0.0 100.0 244

Antenatal care visits
1

None 1.5 0.0 0.2 95.8 2.4 0.0 100.0 2,414
1-3 6.5 0.6 1.3 90.2 1.3 0.0 100.0 1,643
4+ 29.3 6.3 4.4 57.7 2.3 0.0 100.0 680

Total 7.0 1.0 1.1 88.9 2.0 0.1 100.0 6,978
Note: Total includes 9 births with missing information on antenatal care visits which are not shown
separately.
SLC = School Leaving Certificate
1
Includes only the most recent birth in the five years preceding the survey


Maternal and Child Health * 149
ASSISTANCE DURING DELIVERY

Assistance by skilled health personnel during delivery is considered to be effective in the re-
duction of maternal and neonatal mortality. Births delivered at home are usually more likely to be
delivered without assistance from a health professional, whereas births delivered at health facilities
are more likely to be delivered by health personnel with at least minimal training in the provision of
normal delivery services.

Table 9.6 and Figure 9.1 show the percent distribution of live births in the five years preced-
ing the survey by the type of person providing assistance during delivery according to background
characteristics. Only 13 percent of deliveries are assisted by health professionals, that is, doctors,
nurses or ANMs, HAs or AHWs, MCHWs, and VHWs. Of these, 8 percent are doctors and 3 per-
cent are nurses or ANMs. Contrary to expectations, the proportion of deliveries assisted by MCHWs
is very low (less than 1 percent) in spite of the fact that in Nepal, MCHWs have been assigned to
subhealth posts for the promotion of maternal and child health services. This finding suggests that
MCHWs are either not properly deployed or they are not very effective in providing delivery ser-
vices.

Although traditional birth attendants are considered to be less effective in reducing maternal
deaths, TBAs continue to play a prominent role in assisting deliveries, especially in rural areas. The
contribution of TBAs to providing delivery care remained almost the same over the last ten years at
about 23 percent. More than half of births are assisted by relatives, friends, and other nonhealth per-
sonnel, while about one in ten births are delivered without any assistance at all.

Differences in delivery assistance by background characteristics are marked. This is espe-
cially obvious for assistance provided by doctors. Births to young mothers below age 20 and first
order births are more likely to receive assistance from doctors during delivery. Urban births are
seven times more likely than rural births to be delivered by doctors. Delivery assistance from doc-
tors is about three times as high in the hills and terai (more than 8 percent) than in the mountains (3
percent). Similarly, a higher proportion of deliveries in the Central development region (10 percent)
are assisted by doctors than in the other development regions.

Womens education is positively associated with deliveries by medical professionals. For
example, only 4 percent of births to women with no education were assisted by a doctor, compared
with 48 percent of births to women with at least an SLC. This could probably be attributed to the
fact that women with higher levels of education mostly come from urban areas where the services of
a doctor are more readily available.
150 * Maternal and Child Health

Table 9.6 Assistance during delivery
Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, according
to background characteristics, Nepal 2001


Background
characteristic Doctor
Nurse/
auxiliary
nurse
midwife
Health
assistant/
auxiliary
health
worker
Maternal
child
health
worker
Village
health
worker
Tradi-
Tional
birth at-
tendant
Relative/
friend/
other No one Total
Number
of
births

Mothers age at birth
<20 10.7 4.5 2.1 0.5 0.1 24.7 53.2 4.1 100.0 1,290
20-34 7.6 3.0 1.2 0.4 0.2 23.4 55.2 8.8 100.0 5,043
35-49 3.1 0.7 1.2 0.4 0.3 20.4 57.2 16.7 100.0 645

Birth order
1 16.1 6.2 2.6 0.6 0.2 23.0 48.5 2.7 100.0 1,665
2-3 7.2 2.8 1.2 0.5 0.2 25.0 55.7 7.2 100.0 2,790
4-5 3.2 1.6 1.0 0.1 0.3 23.2 58.0 12.7 100.0 1,534
6+ 2.6 0.8 0.5 0.4 0.1 19.8 59.5 16.4 100.0 990

Residence
Urban 39.4 10.9 0.8 0.0 0.0 9.4 35.9 3.5 100.0 449
Rural 5.6 2.5 1.4 0.4 0.2 24.4 56.4 9.0 100.0 6,529

Ecological zone
Mountain 3.0 1.0 0.8 0.7 0.2 10.1 71.4 12.8 100.0 535
Hill 8.3 2.6 1.2 0.7 0.2 7.0 67.1 12.9 100.0 2,873
Terai 8.1 3.7 1.6 0.2 0.2 38.6 42.9 4.6 100.0 3,570

Development region
Eastern 7.9 5.4 1.9 0.1 0.3 25.6 49.5 9.2 100.0 1,610
Central 10.4 2.5 1.3 0.2 0.2 29.2 47.6 8.6 100.0 2,310
Western 7.7 3.9 1.0 1.4 0.1 17.8 58.5 9.6 100.0 1,261
Mid-western 3.7 0.4 1.7 0.3 0.2 19.4 68.0 6.1 100.0 1,048
Far-western 5.6 2.1 0.4 0.2 0.1 15.8 65.9 9.6 100.0 749

Subregion
Eastern Mountain 6.0 1.4 2.5 0.4 0.4 6.0 58.5 24.8 100.0 107
Central Mountain 2.7 1.8 0.6 1.2 0.0 2.1 77.6 13.7 100.0 177
Western Mountain 1.8 0.2 0.2 0.5 0.2 17.5 72.6 6.9 100.0 251
Eastern Hill 4.8 1.9 1.2 0.0 0.6 9.9 64.9 16.7 100.0 533
Central Hill 16.7 4.0 1.3 0.2 0.0 6.6 54.4 16.7 100.0 692
Western Hill 10.3 5.0 1.8 2.5 0.2 8.9 59.0 12.3 100.0 683
Mid-western Hill 2.2 0.3 0.5 0.0 0.0 4.7 83.4 8.9 100.0 634
Far-western Hill 4.1 0.6 1.0 0.2 0.0 3.4 82.5 8.1 100.0 330
Eastern Terai 9.9 7.7 2.3 0.1 0.1 36.4 40.1 3.2 100.0 969
Central Terai 8.3 1.9 1.5 0.1 0.3 43.3 40.6 4.1 100.0 1,441
Western Terai 4.6 2.6 0.0 0.2 0.0 28.3 57.9 6.4 100.0 578
Mid-western Terai 7.5 1.0 4.4 0.8 0.8 47.1 37.4 1.0 100.0 318
Far-western Terai 9.1 5.0 0.0 0.2 0.2 33.1 39.4 12.3 100.0 264

Mothers education
No education 3.7 1.5 1.0 0.2 0.2 25.6 58.2 9.5 100.0 5,176
Primary 9.7 4.4 2.5 0.8 0.2 19.4 53.9 8.9 100.0 970
Some secondary 23.9 9.2 2.3 1.3 0.2 16.3 42.9 4.0 100.0 587
SLC and above 47.8 16.3 2.6 1.1 0.0 9.9 20.8 1.6 100.0 244

Total 7.8 3.1 1.4 0.4 0.2 23.4 55.0 8.6 100.0 6,978
Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is consid-
ered in this tabulation. Total includes births for whom information on assistance at delivery is missing and not shown separately.
SLC = School Leaving Certificate


Maternal and Child Health * 151

USE OF HOME DELIVERY KIT

The clean home delivery kit was developed in the early 1990s by Maternal Child Health
Products with funding from USAID. It is a social marketing product now supported by other donors
as well as by revenue from sales. It is not widely marketed, however, and in some donor or NGO-
supported areas it is available at no cost. Where it is sold, the average cost is about Rps. 25 or about
US$0.33 per unit. The kit contains a new razor blade, clean threads, hand soap, a plastic sheet to
place under the woman, a plastic disc (used to replace the traditional coin placed under the cord
when it is cut), and pictorial instructions. Since most babies are delivered at home with the assis-
tance of elders or relatives and TBAs, use of the clean home delivery kit could play an important role
in reducing neonatal tetanus and other infections.

Table 9.7 provides information on the use of the
clean home delivery kits by type of residence and ecologi-
cal zone. A clean delivery kit was used in only 9 percent of
home deliveries. Although use of clean delivery kits in
home deliveries has improved over the last five years
(from 2 percent in 1996 to 9 percent in 2001), it has still
not reached the bulk of Nepalese mothers. Home deliveries
in urban areas are more likely to involve these delivery kits
(14 percent) than home deliveries in rural areas (9 per-
cent). Likewise, clean delivery kits are more likely to be
used in the terai (12 percent) than in the hills or mountains
(6 percent each). In terms of development regions, births in
the Eastern and Western regions are more likely to involve
clean delivery kits than births in the other regions.
DELIVERY CHARACTERISTICS

Less than 1 percent of births in Nepal are delivered
by caesarean section (Table 9.8). This could in part be due
to the high percentage of home deliveries coupled with a
weak health care referral system. Births to older women,
first order births, births in urban areas, births in the hill
ecological zone, births in the Central development region,
and births to women with at least an SLC are more likely to be delivered by caesarean section. There
has been little change in the percentage of deliveries by caesarean section over the last five years.

Babies in Nepal are usually not weighed at birth since most deliveries take place outside an
institutional setting. Thus, it is difficult to know whether the baby was underweight at birth. To
overcome this, respondents were asked to provide an assessment of their childs size at birth. This
type of assessment is subject to considerable error for individual births. However, at the aggregate
level, it has been observed that there is a strong association between the actual weight at birth and a
mothers perception of the size of her child at birth.

In the absence of birth weight, a mothers assessment of the size of the baby at birth can be a
useful measure of the survival chances of a child. The 2001 NDHS data indicate that about one in
five births (21 percent) was reported as being very small or smaller than average. Births in the moun-
tain ecological zone and Far-western development region and births to mothers with low levels of
education are more likely to be reported as being very small or smaller than average. Nearly 80 per-
cent of the mothers report that their baby was of average size or larger at birth.
Table 9.7 Use of clean home delivery kits
Percentage of births delivered at home in the
five years preceding the survey in which a
clean home delivery kit was used, by resi-
dence and region, Nepal 2001


Residence
and region
Clean
home
delivery
kit used
Number
of
births

Residence
Urban 13.8 242
Rural 9.2 5,960

Ecological zone
Mountain 6.3 502
Hill 6.4 2,523
Terai 12.3 3,177

Development region
Eastern 12.0 1,445
Central 8.5 1,992
Western 11.7 1,096
Mid-western 5.9 977
Far-western 8.0 692

Total 9.4 6,202
152 * Maternal and Child Health

Table 9.8 Delivery characteristics
Percentage of live births in the five years preceding the survey delivered by caesarean
section, and percent distribution by mother's estimate of baby's size at birth, according
to background characteristics, Nepal 2001


Size of child at birth


Background
characteristic
Delivery
by C-
section
Very
small
Smaller
than
average
Average
or larger Total
Number
of
births

Mothers age at birth
<20 0.7 7.1 16.9 75.8 100.0 1,290
20-34 0.8 5.6 14.2 80.1 100.0 5,043
35-49 1.0 7.3 16.8 75.9 100.0 645

Birth order
1 1.6 6.8 17.5 75.5 100.0 1,665
2-3 0.8 5.1 12.7 82.1 100.0 2,790
4-5 0.4 6.5 13.9 79.6 100.0 1,534
6+ 0.5 6.8 18.9 74.4 100.0 990

Residence
Urban 4.8 7.4 13.4 79.0 100.0 449
Rural 0.6 5.9 15.1 78.9 100.0 6,529

Ecological zone
Mountain 0.3 16.9 14.1 68.9 100.0 535
Hill 1.1 7.4 15.8 76.7 100.0 2,873
Terai 0.7 3.4 14.4 82.1 100.0 3,570

Development region
Eastern 1.0 5.4 13.5 81.0 100.0 1,610
Central 1.2 4.7 12.1 83.1 100.0 2,310
Western 0.8 5.5 14.5 79.9 100.0 1,261
Mid-western 0.1 5.1 18.8 76.2 100.0 1,048
Far-western 0.3 13.8 22.3 63.5 100.0 749

Subregion
Eastern Mountain 0.7 6.4 16.0 77.7 100.0 107
Central Mountain 0.6 20.0 6.6 73.1 100.0 177
Western Mountain 0.0 19.1 18.7 62.2 100.0 251
Eastern Hill 0.4 7.6 13.2 79.1 100.0 533
Central Hill 2.7 8.0 12.3 79.5 100.0 692
Western Hill 1.3 7.8 11.7 80.3 100.0 683
Mid-western Hill 0.0 5.5 19.8 74.7 100.0 634
Far-western Hill 0.3 8.4 27.9 63.7 100.0 330
Eastern Terai 1.4 4.1 13.4 82.4 100.0 969
Central Terai 0.6 1.3 12.7 86.1 100.0 1,441
Western Terai 0.3 2.7 17.8 79.4 100.0 578
Mid-western Terai 0.3 4.2 19.2 76.6 100.0 318
Far-western Terai 0.5 12.3 14.4 72.3 100.0 264

Mothers education
No education 0.4 6.0 16.3 77.5 100.0 5,176
Primary 1.1 7.3 11.4 81.2 100.0 970
Some secondary 1.9 4.7 11.6 83.4 100.0 587
SLC and above 6.1 4.3 7.7 88.0 100.0 244

Total 0.8 6.0 15.0 78.9 100.0 6,978
Note: Total includes births for whom information on size at birth is not known or miss-
ing and not shown separately.
SLC = School Leaving Certificate


Maternal and Child Health * 153

9.3 POSTNATAL CARE

The National Safe Motherhood program recommends that mothers should have a postnatal
checkup within two days of delivery. This recommendation is based on the fact that a large number
of maternal and neonatal deaths occur during the 48 hours after delivery. To assess the extent of
postnatal care utilization, respondents who had a birth in the five years preceding the survey were
asked whether they received a postnatal checkup after the delivery of their last birth. Table 9.9
shows the timing of postnatal checkups for the most recent birth that occurred outside a health facil-
ity. The timing of the first postnatal checkup was not asked of mothers who had an institutional birth
because it is assumed that these mothers would normally receive postnatal care within the first two
crucial days after delivery as part of their routine care.

Postnatal care is uncommon in Nepal. Seventy-nine percent of mothers who delivered outside
a health facility do not receive any postnatal checkup. Less than one in five mothers receive postnatal
care within the first two days after delivery.

Postnatal care utilization varies by place of residence. Rural women are slightly more likely
to receive postnatal care within two days of delivery, compared with urban women (17 percent and
13 percent, respectively). Women from the terai ecological zone, Central development region, and
Central terai are more likely to receive postnatal care within the first two days of delivery than
women from other regions. A somewhat higher percentage of women having no education receive
postnatal care within two days of delivery than women having at least an SLC level of education.
This anomaly may be because a smaller percentage of deliveries in urban areas and to educated
women occur at home, and it could be specific to women or families who have reservations about
utilizing health facilities for deliveries.

9.4 REPRODUCTIVE HEALTH CARE AND WOMENS STATUS

Table 9.10 shows whether a womans use of reproductive health services varies by her level
of empowerment as measured by three indicators: her participation in decisionmaking, her attitudes
toward a womans right to refuse sex with her husband, and her attitudes toward wife beating. The
more say a woman has in decisionmaking, the greater control she has over her reproductive needs.
Similarly, empowerment over her reproductive needs is likely to vary positively with the number of
reasons she believes a woman is justified in refusing sex with her husband. On the other hand, em-
powerment over her reproductive needs is likely to vary negatively relative to the number of reasons
she believes wife beating is justified.

In the case of Nepal, there is little variation in the utilization of reproductive health services
by womens decisionmaking autonomy. However, there is a positive relationship between utilization
of reproductive health services and womens empowerment as measured by her attitude toward
womens ability to refuse sex with their husband. For example, one in two women who believe that
a woman can refuse sex with her husband for three or four reasons receives antenatal care services,
compared with only one in three women who believe a wife should refuse sex with her husband for
any reason at all. There appears to be a mixed association between womens empowerment as
measured by the number of reasons women believe that wife beating is justified and their care-
seeking behavior. For example, half as many women who believe that wife beating is not justified
for any reason at all receive postnatal care within the first two days of delivery as women who be-
lieve that wife beating is justified for five reasonsa positive association. On the other hand, twice
as many women in the former group receive delivery assistance from a health professional as women
in the latter groupa negative association.

154 * Maternal and Child Health
Table 9.9 Postnatal care by background characteristics
Percent distribution of women who had a noninstitutional live birth in the five years preceding the survey by tim-
ing of postnatal care for the most recent noninstitutional birth, according to background characteristics, Nepal
2001


Timing of first postnatal checkup


Background
characteristic
Within 2
days of
delivery
3-6 days
after
delivery
7-41 days
after
delivery
Did not
receive
postnatal
checkup
1
Total
Number
of
women

Age at birth
<20 18.0 1.1 3.7 77.2 100.0 675
20-34 17.7 0.8 2.7 78.7 100.0 3,082
35-49 12.8 0.4 1.5 85.4 100.0 534

Birth order
1 17.5 1.9 3.7 77.0 100.0 791
2-3 17.1 0.8 3.1 78.9 100.0 1,715
4-5 17.5 0.1 2.4 80.0 100.0 1,061
6+ 16.3 0.8 1.0 81.9 100.0 724

Residence
Urban 12.6 0.5 5.1 81.8 100.0 180
Rural 17.3 0.8 2.6 79.2 100.0 4,111

Ecological zone
Mountain 1.8 0.4 0.8 97.1 100.0 350
Hill 2.0 0.4 2.1 95.5 100.0 1,781
Terai 32.1 1.2 3.5 63.1 100.0 2,160

Development region
Eastern 13.2 1.5 4.0 81.2 100.0 986
Central 39.4 0.6 2.3 57.7 100.0 1,335
Western 8.5 0.8 2.1 88.6 100.0 838
Mid-western 0.5 0.6 2.7 96.1 100.0 663
Far-western 1.1 0.2 2.0 96.6 100.0 470

Subregion
Eastern Mountain 4.9 0.5 0.5 94.0 100.0 69
Central Mountain 1.4 0.5 0.5 97.7 100.0 117
Western Mountain 0.7 0.4 1.1 97.9 100.0 163
Eastern Hill 2.3 0.3 2.7 94.7 100.0 331
Central Hill 2.6 0.7 3.6 93.1 100.0 378
Western Hill 3.8 0.8 1.9 93.4 100.0 465
Mid-western Hill 0.0 0.0 1.4 98.6 100.0 393
Far-western Hill 0.0 0.0 0.3 99.7 100.0 214
Eastern Terai 20.3 2.3 5.2 72.1 100.0 586
Central Terai 61.2 0.5 2.0 36.3 100.0 840
Western Terai 14.3 0.8 2.4 82.4 100.0 372
Mid-western Terai 1.6 2.0 6.1 90.3 100.0 205
Far-western Terai 2.5 0.3 4.6 92.5 100.0 156

Education
No education 18.8 0.6 2.2 78.3 100.0 3,289
Primary 11.4 0.6 3.4 84.6 100.0 601
Some secondary 11.7 1.9 4.8 81.6 100.0 315
SLC and above 14.5 5.4 8.0 72.1 100.0 86

Total 17.1 0.8 2.7 79.3 100.0 4,291
Note: Total includes women for whom information on timing or postnatal care is not known or missing and
not shown separately.
SLC = School Leaving Certificate
1
Includes women who received the first postnatal checkup after 41 days

Maternal and Child Health * 155

Table 9.10 Reproductive health care by women's status
Percentage of women who had a live birth in the five years preceding the survey, who received antenatal care
and postnatal care from a medical professional for the most recent birth, and percentage of births in the five
years preceding the survey for which mothers received professional delivery care, by women's status indicators,
Nepal 2001


Women's status
indicator
Percentage of
women who re-
ceived antenatal
care from a
doctor/nurse/
ANM/HA/
AHW/MCHW/
VHW

Percentage of
women who re-
ceived postnatal
care within the
first two days of
delivery
1




Number
of
women
Percentage of
births for whom
mothers received
delivery care
from a doctor/
nurse/ANM/HA/
AHW/MCHW/
VHW
Number
of
births

Number of decisions in which
woman has final say
2


0 52.8 26.0 758 13.7 1,061
1-2 46.3 24.6 2,276 11.8 3,460
3-4 51.5 27.0 935 14.7 1,347
5 47.7 23.2 777 13.2 1,110

Number of reasons to refuse
sex with husband

0 33.7 13.9 55 6.5 84
1-2 35.6 19.7 144 14.4 213
3-4 49.1 25.4 4,547 12.9 6,681

Number of reasons
wife beating is justified

0 48.3 24.4 3,357 13.1 4,932
1-2 48.3 20.8 1,095 12.2 1,601
3-4 53.1 48.6 240 14.6 358
5 50.1 46.4 53 6.0 87

Total 48.6 25.1 4,745 12.9 6,978
ANM = Auxiliary nurse midwife
HA = Health assistant
AHW = Auxiliary health worker
MCHW = Maternal child health worker
VHW = Village health worker

1
Includes mothers who delivered in a health facility
2
Either by herself or jointly with others



9.5 VACCINATION OF CHILDREN

Universal immunization of children under one year of age against the six vaccine-preventable
diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles) is one of the most
cost-effective programs in reducing infant and child morbidity and mortality. The expanded program
on immunization (EPI) is a priority program for the government of Nepal. Among the immediate ob-
jectives of the program are: to reduce measles cases by 90 percent and deaths due to measles by 95
percent from previous levels by the year 2000; and to eradicate polio by the year 2000 (Ministry of
Health, 2001). Since 1988, the expanded program on immunization under the Ministry of Health has
covered all 75 districts of Nepal. The program in Nepal follows the guidelines set by the World
Health Organization. To be fully immunized, a child should receive the following vaccinations: one



156 * Maternal and Child Health


dose of BCG, three doses each of DPT and polio, and one dose of measles vaccine. BCG, which is
given at birth or at first clinical contact, protects against tuberculosis. DPT protects against diphthe-
ria, pertussis, and tetanus. DPT and polio each require three vaccinations at approximately six, ten,
and 14 weeks of age; however, since this regime is not always followed, emphasis is given on getting
all three doses by the time the child reaches 12 months of age. Measles should be given at or soon
after the child reaches nine months. It is recommended that children receive the complete schedule
of vaccinations before 12 months of age. Children who receive protection against all six vaccine-
preventable illnesses are considered fully vaccinated.

In addition to the routine doses of polio vaccines given during clinical visits, the EPI program
in Nepal includes supplemental immunization activities, including national immunization days
(NIDs) for polio eradication and outbreak response immunization for all cases in high-risk areas
(Ministry of Health, 2001). The NIDs have been held regularly since 1996 and more recently a modi-
fication of the immunization strategy has resulted in intensive national immunization days, including
sub-national immunization days (SNIDs) and mopping-up rounds.

The 2001 NDHS collected information on childhood immunization coverage, including im-
munizations received during national immunization day campaigns, for all living children born in the
five years preceding the survey. This information is important for the monitoring and evaluation of
the EPI. Information on vaccination coverage was collected in two ways: from vaccination cards
shown to the interviewer and from mothers verbal reports. If the cards were available, the inter-
viewer copied the vaccination dates directly onto the questionnaire. When a vaccination card for the
child was not seen or if a vaccine had not been recorded as being given, the mother was asked to re-
call the vaccines given to her child. In Nepal, mothers often do not receive or keep vaccination cards,
so most data depends on accurate recall of their childrens vaccination. Information was also col-
lected on whether a child ever had a vaccination card. Table 9.11 shows the percentage of children
age 12-23 months who have received the various vaccinations by source of information, that is, from
vaccination card or mothers report. This is the youngest cohort of children who have reached the
age by which they should be fully immunized.


Table 9.11 Vaccinations by source of information
Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information
(vaccination card or mother's report), and percentage vaccinated by 12 months of age, Nepal 2001

DPT Polio
1

Source of
information BCG 1 2 3 0 1 2 3 Measles All
2

No
vacci-
nations
Number
of
children

Vaccinated at any
time before survey

Vaccination card 16.1 15.8 15.2 14.2 0.3 16.0 15.9 15.5 12.9 12.5 0.0 212
Mother's report 68.3 68.1 63.5 58.0 1.7 83.0 82.6 76.0 57.7 53.1 0.9 1,101
Either source 84.5 84.0 78.7 72.1 2.0 99.0 98.5 91.5 70.6 65.6 0.9 1,313

Vaccinated by 12
months of age
3


82.9

82.5

77.4

70.6

2.0

97.3

96.4

90.4

63.6

60.1

3.4

1,313


1
Polio 0 is the polio vaccination given at birth.
2
BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth)
3
For children whose information was based on the mothers report, the proportion of vaccinations given during the first year of
life was assumed to be the same as for children with a written record of vaccination.


Maternal and Child Health * 157

Sixty percent of children are fully vaccinated by 12 months of age, 83 percent have received
the BCG vaccination, and 64 percent have been vaccinated against measles. Coverage for the first
dose of DPT is 83 percent, but this drops to 77 percent for the second dose and further to 71 percent
for the third dose. Polio coverage is much higher at 97 percent for the first dose, 96 percent for the
second dose, and 90 percent for the third dose. Although DPT and polio vaccinations are provided at
the same time, polio coverage is much higher than DPT coverage primarily because of the success of
the intensive national immunization day campaigns and other polio eradication activities. The Nepal
Micronutrient Status Survey (NMSS), carried out in 1998, also showed a very high coverage for po-
lio (96 percent) among children age 12-23 months (Ministry of Health, 1999).

Vaccination coverage has improved significantly over the last five years (Figure 9.2). The
percentage of children age 12-23 months who are fully immunized by 12 months of age increased by
67 percent, from 36 percent in 1996 (Pradhan et al., 1997) to 60 percent in 2001. Coverage with all
three doses of DPT increased from 51 to 71 percent of children, while complete polio coverage in-
creased from 48 to 90 percent of children. BCG coverage increased from 73 to 83 percent, and mea-
sles vaccination increased from 45 to 64 percent.
73
51
48
45
36
24
83
71
90
64
60
3
BCG DPT3 Polio 3 Measles All vacci-
nations
None
0
20
40
60
80
100
Percent
NFHS 1996 NDHS 2001
Figure 9.2 Percentage of Children Age 12-23 Months
Who Received Specific Vaccinations by 12 Months
of Age, 1996 and 2001

Table 9.12 presents vaccination coverage at any time before the survey (according to infor-
mation from vaccination cards and mothers reports) among children age 12-23 months by back-
ground characteristics. Male children are slightly more likely to be fully immunized than female
children (68 percent versus 64 percent). Birth order has a negative relationship with vaccination
coverageas the birth order increases vaccination coverage decreases. More than 71 percent of first
and second order births were fully immunized, compared with only 54 percent for sixth and higher
order births.
158 * Maternal and Child Health

Table 9.12 Vaccinations by background characteristics
Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or
the mother's report), and percentage with a vaccination card, by background characteristics, Nepal 2001

DPT Polio
1




Background
characteristic



BCG

1

2

3

0

1

2

3



Measles



All
2


No
vacci-
nations
Percentage
with a
vaccination
card seen

Number
of
children

Sex
Male 86.1 85.8 81.8 74.2 2.9 99.3 99.0 92.1 72.9 67.5 0.7 17.3 631
Female 82.9 82.3 75.8 70.2 1.2 98.7 98.1 90.9 68.5 63.9 1.0 15.1 682

Birth order
1 90.5 91.2 87.1 78.2 2.9 98.6 98.6 95.2 76.3 71.6 1.4 20.6 326
2-3 87.9 87.1 82.3 77.7 2.7 99.1 98.5 93.1 74.9 71.1 0.9 15.4 531
4-5 79.4 78.5 70.9 62.8 0.7 98.6 97.8 89.0 62.1 55.6 0.8 15.0 265
6+ 71.7 70.4 65.1 59.2 0.4 100.0 99.4 84.1 60.7 54.0 0.0 12.2 190

Residence
Urban 88.4 88.0 86.4 78.2 6.2 100.0 98.2 95.4 80.6 74.9 0.0 17.5 87
Rural 84.2 83.7 78.1 71.7 1.7 98.9 98.5 91.2 69.9 65.0 0.9 16.1 1,226

Ecological zone
Mountain 78.0 78.5 71.5 67.0 0.6 99.4 98.4 85.0 72.3 63.5 0.6 8.8 95
Hill 83.3 82.4 80.3 76.8 2.8 98.2 98.0 89.7 73.2 70.4 1.5 12.9 564
Terai 86.4 86.1 78.3 68.8 1.5 99.6 99.0 94.0 68.1 61.8 0.4 20.0 654

Development region
Eastern 92.5 92.1 88.6 81.0 3.6 100.0 99.5 96.5 78.6 73.8 0.0 21.5 303
Central 84.9 84.6 76.8 67.3 0.9 98.9 98.7 91.7 64.9 60.0 1.1 12.6 423
Western 84.8 84.5 77.9 73.1 3.2 97.3 96.9 93.2 68.0 64.8 2.7 22.4 230
Mid-western 81.7 80.5 78.6 74.0 1.2 99.2 98.7 86.4 76.1 69.9 0.0 9.9 216
Far-western 69.5 68.7 64.1 63.2 1.0 99.6 98.3 85.3 66.5 59.7 0.4 15.0 141

Subregion
Eastern Mountain (74.4) (82.1) (74.4) (71.8) (0.0) (100.0) (97.4) (84.6) (74.4) (71.8) (0.0) (12.8) 15
Central Mountain 91.3 92.8 85.5 81.2 0.0 98.6 98.6 92.8 79.7 76.8 1.4 14.5 36
Western Mountain 68.0 65.3 58.7 53.3 1.3 100.0 98.7 78.7 65.3 49.3 0.0 2.7 43
Eastern Hill 93.1 92.2 91.2 86.3 3.9 100.0 100.0 98.0 76.5 75.5 0.0 15.7 112
Central Hill 82.6 80.1 80.1 77.0 1.9 98.1 98.1 86.8 70.0 68.5 1.9 16.4 132
Western Hill 90.3 91.4 87.1 83.9 6.1 95.7 95.7 94.6 77.4 76.3 4.3 16.8 122
Mid-western Hill 81.3 80.0 78.8 75.0 1.3 98.8 98.8 85.0 77.5 73.8 0.0 5.0 133
Far-western Hill 58.3 58.3 52.4 50.5 0.0 99.0 97.1 81.8 57.3 47.6 1.0 9.8 64
Eastern Terai 93.6 92.9 88.2 78.4 3.8 100.0 99.3 96.5 80.2 72.9 0.0 25.9 176
Central Terai 85.2 85.8 73.9 60.3 0.6 99.4 99.0 94.1 60.1 53.2 0.6 10.3 255
Western Terai 78.7 76.9 67.6 61.1 0.0 99.1 98.1 91.7 57.4 51.9 0.9 28.7 109
Mid-western Terai 83.1 82.7 80.6 76.8 1.3 100.0 99.2 90.3 73.4 66.7 0.0 22.4 66
Far-western Terai 88.8 87.8 85.7 85.7 1.7 100.0 99.0 94.8 82.5 81.8 0.0 27.6 49

Mothers education
No education 79.7 78.8 72.5 64.3 1.1 98.6 98.1 89.0 63.2 57.0 1.2 14.3 931
Primary 94.4 94.7 90.8 87.8 3.2 100.0 99.4 96.5 84.6 83.2 0.0 19.6 191
Some secondary 96.7 97.9 96.2 93.6 4.5 100.0 99.2 98.5 92.9 89.6 0.0 22.1 132
SLC and above 100.0 100.0 97.8 96.4 6.6 100.0 100.0 100.0 93.1 90.9 0.0 20.8 58

Total 84.5 84.0 78.7 72.1 2.0 99.0 98.5 91.5 70.6 65.6 0.9 16.2 1,313
Note: Figures in parentheses are based on 25-49 unweighted cases.
SLC = School Leaving Certificate

1
Polio 0 is the polio vaccination given at birth.
2
BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth)


Maternal and Child Health * 159

As expected, urban coverage (75 percent) is higher than rural coverage (65 percent); how-
ever, the gap has narrowed over the last five years. This indicates that there has been considerable
improvement in immunization coverage in rural areas, while a relatively smaller change occurred in
urban areas. The percentage of children age 12-23 months fully immunized is higher among children
residing in the hill ecological zone than among children residing in the mountain and terai zones. In
spite of the fact that transportation is better in the terai and it is easier to maintain a cold-chain, the
coverage in that zone is lower. This could be attributed to a higher dropout in the third dose of DPT
and a lower coverage for the measles vaccination. The Eastern development region has the highest
immunization coverage (74 percent) compared with the other development regions. Immunization
coverage is highest in the Far-western terai subregion (82 percent).

The percentage of children fully immunized increases with mothers educational level. For
example, only 57 percent of children of mothers with no education are fully immunized, compared
with 91 percent of children whose mothers have completed an SLC or above.

Vaccination cards were seen for 16 percent of children, with first order births and children
from the terai region the most likely to have cards. Educated mothers are also more likely to show a
vaccination card than mothers with little or no education.

9.6 PREVALENCE AND TREATMENT OF ARI AND FEVER
ACUTE RESPIRATORY INFECTION

Acute respiratory infection (ARI) is one of the leading causes of childhood morbidity and
mortality in Nepal. The ARI program focuses on its early diagnosis and treatment with antibiotics,
which can prevent a large proportion of deaths due to pneumonia. Therefore, emphasis is placed in
the early recognition of the signs of ARI and its impending severity by primary health care workers
and health volunteers. In the 2001 NDHS, the prevalence of ARI was estimated by asking mothers
whether their children below five years of age had been sick with a cough accompanied by short,
rapid breathing in the two weeks preceding the survey. These symptoms are compatible with ARI. It
should be noted that morbidity data are subjective since the information is based on a mothers per-
ception of her childs illness without any medical diagnosis. The prevalence of ARI is also subject to
seasonality.

Table 9.13 shows that 23 percent of children below five years of age had symptoms of ARI at
some time in the two weeks preceding the survey. The prevalence of ARI varies with the age of the
child. Prevalence was highest among children 6-11 months of age. The prevalence of ARI decreases
with increasing age. There are no significant differences in the prevalence of ARI by sex of the child
and urban-rural residence. However, there are marked differences by region of residence. The
prevalence of ARI is lowest in the hill zone (20 percent) compared with the terai and mountain
zones. Prevalence is also lowest in the Mid-western region (15 percent) and highest in the Eastern
region (30 percent) compared with the other development regions.

ARI prevalence varied little by mothers education, with the exception of children of mothers
with at least an SLC level of education, who are least likely to show symptoms of ARI. Prevalence is
also slightly higher among children whose mothers smoke cigarettes or other tobacco (25 percent)
than among children of mothers who do not smoke (22 percent).
160 * Maternal and Child Health

Table 9.13 Prevalence and treatment of symptoms of ARI and fever
Percentage of children under five years who had a cough accompanied by short, rapid breathing (symptoms of ARI) in the two
weeks preceding the survey, and percentage who had fever in the two weeks preceding the survey, and among children with
symptoms of ARI and/or fever, percentage for whom treatment was sought from a health facility or provider, by background
characteristics, Nepal 2001


Background
characteristic
Children
with
symptoms
of ARI
Children
with fever
Number
of
children
Children with
symptoms of
ARI and/or fever, for
whom treatment
was sought from
a health
facility/provider
1
Number
of
children

Age in months
<6 28.1 27.9 651 21.6 259
6-11 36.3 47.8 631 27.9 357
12-23 27.7 40.9 1,313 25.8 626
24-35 21.5 32.4 1,245 19.4 481
36-47 17.7 26.1 1,329 21.8 419
48-59 15.0 22.8 1,301 25.5 354

Sex
Male 23.7 32.1 3,194 25.9 1,238
Female 21.8 31.8 3,277 21.6 1,259

Residence
Urban 23.8 26.7 431 33.3 158
Rural 22.7 32.3 6,040 23.1 2,338

Ecological zone
Mountain 31.7 32.9 480 21.7 198
Hill 20.3 30.3 2,698 23.7 947
Terai 23.5 33.2 3,292 24.0 1,351

Development region
Eastern 30.0 35.1 1,499 28.5 662
Central 25.4 35.7 2,126 20.0 918
Western 18.4 27.0 1,196 29.7 397
Mid-western 15.1 27.1 975 17.7 297
Far-western 17.4 29.0 674 22.7 223

Subregion
Eastern Mountain 29.9 33.7 99 26.9 40
Central Mountain 47.6 40.5 163 19.7 94
Western Mountain 20.7 26.8 218 21.4 65
Eastern Hill 23.7 29.4 498 25.2 166
Central Hill 25.1 30.7 656 29.7 244
Western Hill 22.6 32.8 653 27.1 259
Mid-western Hill 12.4 27.9 593 12.3 177
Far-western Hill 15.0 30.4 298 18.4 101
Eastern Terai 33.5 38.4 901 29.8 456
Central Terai 22.8 37.6 1,306 15.9 579
Western Terai 13.3 20.1 543 34.5 138
Mid-western Terai 22.2 28.9 298 28.4 104
Far-western Terai 14.7 24.6 244 26.5 73

Mothers education
No education 22.6 32.8 4,758 20.9 1,840
Primary 24.6 29.9 915 31.3 353
Some secondary 23.1 30.0 553 33.7 218
SLC and above 18.6 27.6 244 28.9 86

Mother's smoking status
Smokes cigarettes/tobacco 25.4 na 1,671 na 670
Does not smoke
cigarettes/tobacco

21.9

na

4,799

na

1,826


Total 22.8 32.0 6,471 23.7 2,496
na = Not applicable
ARI = Acute respiratory infection
SLC = School Leaving Certificate
1
Excludes pharmacy, shop, and traditional practitioner


Maternal and Child Health * 161
FEVER

Fever is a manifestation of malaria, although it also accompanies various other illnesses. Ma-
laria and fever contribute to high levels of malnutrition and high mortality. Although fever can occur
throughout the year, malaria is more prevalent during the rainy season. For this reason, temporal
factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Pre-
sumptive treatment of fever with antimalarial tablets is advocated where malaria is endemic. Table
9.13 shows the percentage of children under five years of age who had fever during the two weeks
preceding the survey.

Thirty-two percent of children under five years of age had fever in the two weeks preceding
the survey. The prevalence of fever varies with the age of the child. One in two children age 6-11
months had fever; this decreases to about one in five children among those age 48-59 months. There
is little variation in the prevalence of fever by sex, but children residing in rural areas have a higher
prevalence of fever (32 percent) than urban children (27 percent). Differences in the prevalence of
fever by ecological region are minor. Prevalence of fever is lowest among children of mothers with
at least an SLC level of education.
TREATMENT OF ARI AND FEVER

Table 9.13 shows the percentage of children with symptoms of ARI and or fever for whom
treatment was sought. As shown by the table, use of a health facility or provider for the treatment of
ARI and/or fever is low in Nepal. Less than one in four children (24 percent) with symptoms of ARI
and/or fever were taken to a health facility or provider for the treatment of ARI. Children age 24-35
months are least likely (19 percent) to be taken for treatment, while those age 6-11 months are most
likely to be taken for treatment (28 percent). A higher proportion of male than female children are
taken for treatment (26 percent versus 22 percent). Likewise a higher proportion of urban than rural
children are taken to a health facility or provider (33 percent versus 23 percent). Children residing in
the Eastern and Western development regions and especially the Western terai subregion are more
likely than other children to be taken for treatment. Children of mothers with no education are least
likely to be taken for treatment (21 percent), compared with mothers with some education.

9.7 DIARRHEA
STOOL DISPOSAL

Diarrhea is frequently caused by the use of contaminated water and unhygienic practices re-
lated to food preparation and excreta disposal. If human feces are left uncontained, diarrheal disease
may spread by direct or indirect contact. So stool disposal practices also play a vital role in the
prevalence of diarrhea.

Table 9.14 presents information on the disposal of the stools of children under five years of
age by background characteristics and type of toilet facilities available in the household. Only 18
percent of childrens stools are contained, that is, the child always uses the toilet facilities or the
childs stool is thrown into the toilet or buried in the yard. On the other hand, 65 percent of chil-
drens stools are either thrown outside the dwelling or yard, while 15 percent of childrens stools are
rinsed away, indicating a high potential in Nepal for the spread of diarrheal diseases from uncon-
tained stools.
162 * Maternal and Child Health

Table 9.14 Disposal of child's stools
Percent distribution of mothers whose youngest child under five years is living with her by way in which child's fecal
matter is disposed of, according to background characteristics and type of toilet facilities in household, Nepal 2001


Stools contained

Stools not contained


Background
characteristic
Child
always
uses
toilet/
latrine
Thrown
into
toilet/
latrine
Buried
in yard
Thrown
outside
dwelling
Thrown
outside
yard
Rinsed
away
Not dis-
posed of Other Total
Number
of
mothers
Residence
Urban 4.0 34.9 8.0 16.1 25.1 8.9 0.5 2.4 100.0 325
Rural 0.6 7.5 7.2 14.1 52.3 15.0 0.9 2.3 100.0 4,286

Ecological zone
Mountain 1.4 7.0 5.6 18.3 44.9 21.1 0.5 1.2 100.0 345
Hill 1.0 15.3 8.3 14.3 45.0 12.7 1.2 2.2 100.0 1,933
Terai 0.5 5.0 6.6 13.6 55.7 15.3 0.7 2.6 100.0 2,333

Development region
Eastern 1.7 10.9 9.8 17.7 42.9 13.4 2.2 1.4 100.0 1,079
Central 1.1 9.2 5.1 6.2 58.7 17.6 0.2 1.9 100.0 1,483
Western 0.0 17.2 10.9 19.6 29.8 14.8 1.0 6.6 100.0 887
Mid-western 0.3 2.7 4.4 9.7 70.2 11.8 0.7 0.3 100.0 676
Far-western 0.4 2.3 5.5 27.6 51.6 11.8 0.1 0.7 100.0 486

Subregion
Eastern Mountain 3.7 16.6 8.6 16.0 36.4 17.6 1.1 0.0 100.0 71
Central Mountain 0.4 7.6 7.2 14.3 30.0 36.8 0.4 3.1 100.0 118
Western Mountain 1.1 2.2 3.0 22.2 60.0 10.7 0.4 0.4 100.0 156
Eastern Hill 4.5 14.6 9.7 12.9 46.6 5.8 3.6 2.3 100.0 340
Central Hill 1.0 22.5 10.0 9.9 37.7 16.6 0.4 1.9 100.0 476
Western Hill 0.0 25.9 12.4 23.2 17.0 16.0 0.8 4.7 100.0 504
Mid-western Hill 0.0 1.3 3.4 4.2 79.4 10.5 1.3 0.0 100.0 397
Far-western Hill 0.0 1.2 2.3 23.6 61.0 11.1 0.0 0.9 100.0 216
Eastern Terai 0.0 8.5 9.9 20.3 41.8 16.7 1.6 1.2 100.0 667
Central Terai 1.2 2.2 2.3 3.2 73.7 15.6 0.0 1.6 100.0 889
Western Terai 0.0 5.8 8.9 14.9 46.7 13.3 1.3 9.2 100.0 383
Mid-western Terai 1.0 5.4 6.8 19.6 50.5 15.7 0.0 0.9 100.0 219
Far-western Terai 0.0 3.8 10.3 31.1 42.8 11.5 0.0 0.6 100.0 175

Education
No education 0.2 4.4 5.2 15.2 57.2 14.8 0.9 2.0 100.0 3,330
Primary 1.9 15.8 10.7 13.4 38.1 15.2 1.2 3.7 100.0 673
Some secondary 2.2 25.5 15.3 11.5 29.5 13.4 0.3 2.5 100.0 423
SLC and above 4.3 41.3 13.7 6.1 20.1 12.4 0.0 2.3 100.0 184

Toilet facilities
None 0.0 1.9 5.4 14.7 58.9 15.7 1.0 2.3 100.0 3,469
Traditional pit toilet 2.1 26.3 14.7 14.7 28.0 11.4 0.7 2.0 100.0 700
Ventilated improved
pit latrine

4.4

31.7

16.7

6.8

25.4

10.3

0.0

4.6

100.0

79

Flush toilet 4.9 44.6 8.2 10.1 17.5 11.7 0.6 2.4 100.0 362

Total 0.8 9.5 7.2 14.2 50.4 14.6 0.9 2.3 100.0 4,611
Note: Total include one mother for whom information on toilet facilities was given as other and women for whom
information on disposal of childs stool is missing, who are not shown separately.
SLC = School Leaving Certificate

Maternal and Child Health * 163

The way in which childrens stools are dis-
posed of varies markedly by urban-rural residence.
Forty-seven percent of urban childrens stools are
contained, compared with only 15 percent in rural
areas. Regional variations exist in the practice of
stool disposal. Hygienic disposal of stools is more
common in the hill ecological zone and in the
Western development region than in the other re-
gions. Not surprisingly, education exerts a posi-
tive influence on the hygienic disposal of chil-
drens stools, as does the availability of toilet fa-
cilities.
PREVALENCE OF DIARRHEA

Diarrhea has been singled out for investiga-
tion for two reasons. Dehydration caused by diar-
rhea is a major cause of morbidity and mortality
among young children, and the condition can be
easily treated by oral rehydration therapy (ORT).
Exposure to agents that cause diarrheal disease is
frequently related to the use of contaminated water
and unhygienic practices of food preparation and
excreta disposal. The most effective way to control
dehydration is to administer oral rehydration ther-
apy promptly.

The Ministry of Health in Nepal has given
high priority to the control of diarrhea through
preventive as well as curative strategies. To re-
duce the severity of symptoms from dehydration,
health education programs promote the use of
ORT. The availability of oral rehydration salt
(ORS) packages all over the country has been in-
creased along with an expanded social marketing
system providing supplies to female community
health volunteers. In the 2001 NDHS, information
was collected on the prevalence of diarrhea among
children under five years of age in the two weeks
before the interview. The information on preva-
lence should be interpreted with caution since the
incidence of diarrhea varies with the season.

Table 9.15 shows the percentage of chil-
dren under five years of age with diarrhea in the
two weeks preceding the survey by selected back-
ground characteristics. One in five children ex-
perienced diarrhea at some time in the two weeks
preceding the survey.
Table 9.15 Prevalence of diarrhea
Percentage of children under five years with diarrhea in
the two weeks preceding the survey, by background char-
acter-istics, Nepal 2001


Background
characteristic
Diarrhea in the
the two weeks
preceding the survey
Number
of
children

Age
<6 18.7 651
6-11 34.5 631
12-23 29.6 1,313
24-35 20.2 1,245
36-47 15.3 1,329
48-59 10.6 1,301

Sex
Male 21.3 3,194
Female 19.5 3,277

Residence
Urban 16.6 431
Rural 20.7 6,040

Ecological zone
Mountain 20.2 480
Hill 18.5 2,698
Terai 22.0 3,292

Development region
Eastern 23.8 1,499
Central 23.2 2,126
Western 17.1 1,196
Mid-western 13.8 975
Far-western 19.2 674

Subregion
Eastern Mountain 21.5 99
Central Mountain 25.2 163
Western Mountain 15.9 218
Eastern Hill 25.7 498
Central Hill 15.9 656
Western Hill 19.5 653
Mid-western Hill 13.1 593
Far-western Hill 21.2 298
Eastern Terai 23.1 901
Central Terai 26.6 1,306
Western Terai 14.3 543
Mid-western Terai 16.7 298
Far-western Terai 16.5 244

Mothers education
No education 21.2 4,758
Primary 20.6 915
Some secondary 16.4 553
SLC and above 13.2 244

Source of drinking water
Piped water 19.7 2,110
Dug well 22.0 2,681
Tubewell/borehole 23.5 259
Surface water 17.8 1,417

Total 20.4 6,471
Note: Total includes 4 children for whom information
on source of drinking water is missing, and not shown
separately.
SLC = School Leaving Certificate

164 * Maternal and Child Health

The incidence of diarrhea varies with age. Prevalence is highest among children age 6-11
months (35 percent). There is little discernible difference in the prevalence of diarrhea by sex of the
child, urban-rural residence, and ecological zone. Prevalence is higher in the Eastern and Central
development regions.

Children of mothers with little or no educa-
tion are also more likely to have diarrhea than chil-
dren of mothers with at least some secondary edu-
cation. Children living in households where the
main source of drinking water is from a well (dug
well, tube well, or borehole) are also more prone to
diarrhea than children living in households with
access to piped drinking water.
KNOWLEDGE OF ORS PACKETS

A major component of ORT is the early
administration of a solution prepared from ORS
packets to prevent dehydration. To assess the
knowledge of ORS in Nepal, mothers were asked
whether they know about ORS packets.

Table 9.16 shows the percentage of mothers
who know about ORS packets for treatment of diar-
rhea among women who gave birth in the five years
preceding the survey. As indicated by the table,
knowledge of ORS packets is nearly universal (98
percent). No discernible differences in knowledge
by background characteristics exist.
DIARRHEA TREATMENT

Table 9.17 provides information on whether
medical care was sought for diarrhea in the two
weeks preceding the survey. The percentage of
children who received specific treatments for diar-
rhea is also shown by selected background charac-
teristics. Particular attention is focused on treatment
with oral rehydration therapy, including the use of
ORS packets, and increased fluids. Oral rehydra-
tion therapy in Nepal includes recommended home
fluids, but the use of oral rehydration salts is the
main method being promoted. Recommended
home fluids according to the Ministry of Health
guidelines include breast milk and other liquids, but
sugar-salt-water solution is no longer being actively
promoted. The policy has also seen a shift in recent
years, emphasizing the importance of giving in-
creased fluid during diarrheal episodes, away from
specifying the types of fluids to be given (NPC,
2000).
Table 9.16 Knowledge of ORS packets
Percentage of mothers with births in the five years preceding
the survey who know about ORS packets for treatment of
diarrhea, by background characteristics, Nepal 2001



Background
characteristic
Percentage of
mothers
who know about
ORS packets


Number of
children

Age
15-19 97.9 379
20-24 98.3 1,370
25-29 98.3 1,354
30-34 97.6 850
35-49 96.0 792

Residence
Urban 98.3 332
Rural 97.7 4,414

Ecological zone
Mountain 95.8 361
Hill 97.6 1,979
Terai 98.2 2,405

Development region
Eastern 97.3 1,102
Central 98.3 1,535
Western 97.3 914
Mid-western 98.8 693
Far-western 96.5 502

Subregion
Eastern Mountain 95.9 74
Central Mountain 99.1 122
Western Mountain 93.4 166
Eastern Hill 97.8 347
Central Hill 97.7 484
Western Hill 96.7 521
Mid-western Hill 99.6 405
Far-western Hill 95.2 223
Eastern Terai 97.3 681
Central Terai 98.5 930
Western Terai 98.0 393
Mid-western Terai 99.3 222
Far-western Terai 99.3 179

Education
No education 97.0 3,437
Primary 99.4 684
Some secondary 99.8 439
SLC and above 100.0 186

Total 97.8 4,745
ORS = Oral rehydration salts
SLC = School Leaving Certificate

Maternal and Child Health * 165


Table 9.17 Diarrhea treatment
Percentage of children under five years who had diarrhea in the two weeks preceding the survey taken for treatment to a health provider,
percentage who received oral rehydration therapy (ORT), and percentage given other treatments, by background characteristics, Nepal
2001

Oral rehydration therapy (ORT) Other treatments

Background
characteristic

Percentage
taken to a
health
provider
1

ORS
packets
Increased
fluids
ORS or
increased
fluids
Pill/
syrup Injection
Intra-
venous
solution
Home
remedy/
other
No
treat-
ment
Number
of
children
Age in months
<6 9.9 11.2 13.3 19.5 24.0 2.4 0.0 2.2 64.2 121
6-11 23.1 23.8 20.7 35.6 42.2 1.5 0.6 7.0 39.1 218
12-23 26.3 39.2 31.3 54.9 44.9 0.8 1.2 5.9 28.8 388
24-35 20.1 32.9 35.4 54.8 35.5 1.2 0.5 8.1 28.1 251
36-47 18.3 41.3 22.8 50.4 34.6 0.9 0.4 6.2 32.5 203
48-59 19.9 29.2 24.4 43.4 28.9 0.0 0.0 14.8 37.4 138

Sex
Male 20.2 32.5 28.2 48.5 37.7 0.9 0.4 6.7 33.4 681
Female 22.2 31.8 24.9 44.4 37.3 1.3 0.8 7.5 36.9 639

Residence
Urban 23.1 45.6 39.2 63.2 43.6 0.0 1.2 4.0 25.7 71
Rural 21.1 31.4 25.9 45.6 37.1 1.1 0.6 7.3 35.6 1,249

Ecological zone
Mountain 28.2 29.1 28.4 48.1 19.2 0.6 0.0 6.9 43.9 97
Hill 23.7 31.2 37.7 52.1 28.1 1.0 0.3 7.8 36.3 500
Terai 18.5 33.2 18.7 42.5 46.4 1.2 0.9 6.7 33.1 723

Development region
Eastern 19.1 38.7 32.3 51.5 33.2 1.7 0.6 8.2 33.6 357
Central 17.6 27.2 16.5 37.7 45.5 0.8 1.2 5.9 36.3 493
Western 30.0 33.8 33.5 52.1 35.6 0.0 0.0 7.6 34.8 205
Mid-western 16.7 27.5 37.3 53.2 26.1 1.2 0.0 10.3 34.1 135
Far-western 31.3 35.5 27.2 50.8 33.9 1.7 0.0 5.1 35.8 130

Subregion
Eastern Mountain 32.1 33.9 50.0 58.9 25.0 0.0 0.0 12.5 30.4 21
Central Mountain 20.5 23.1 24.4 43.6 14.1 0.0 0.0 1.3 51.3 41
Western Mountain 35.0 33.3 20.0 46.7 21.7 1.7 0.0 10.0 43.3 35
Eastern Hill 22.4 42.2 44.8 60.3 16.4 0.0 0.0 12.1 33.6 128
Central Hill 26.4 29.6 34.4 50.0 34.8 2.4 1.2 4.0 35.2 104
Western Hill 29.8 33.2 39.4 55.1 35.6 0.0 0.0 6.2 34.6 127
Mid-western Hill (8.6) (17.2) (37.5) (46.1) (21.6) (2.2) (0.0) (10.8) (40.9) 77
Far-western Hill 27.7 24.7 25.7 40.3 33.7 1.0 0.0 5.0 41.0 63
Eastern Terai 15.7 37.0 22.9 45.3 44.3 3.0 1.0 5.4 34.0 208
Central Terai 14.6 26.9 10.3 33.3 52.4 0.4 1.3 6.9 34.9 348
Western Terai 30.3 34.6 23.8 47.2 35.5 0.0 0.0 10.0 35.1 77
Mid-western Terai 27.4 46.9 38.5 67.0 34.1 0.0 0.0 11.2 19.6 50
Far-western Terai 33.2 48.7 36.2 67.7 42.2 2.6 0.0 0.0 25.4 40

Mothers education
No education 18.7 29.1 21.6 42.5 35.9 1.2 0.5 7.3 37.3 1,009
Primary 27.4 39.0 37.7 55.0 40.6 0.0 1.5 4.8 31.5 188
Some secondary 26.7 43.0 47.0 62.7 40.7 0.0 0.0 8.6 26.8 91
SLC and above (45.9) (57.9) (60.4) (76.5) (60.3) (7.7) (0.0) (10.5) (9.4) 32

Total 21.2 32.2 26.6 46.5 37.5 1.1 0.6 7.1 35.1 1,320
Note: Total includes children with missing information on diarrhea treatment who are not shown separately. Figures in parentheses are based
on 25-49 unweighted cases.
ORS = Oral rehydration salts
SLC = School Leaving Certificate
1
Excludes pharmacy, shop, and traditional practitioner


166 * Maternal and Child Health

One in five children with diarrhea in the two weeks prior to the survey was taken to a health
facility for treatment. Children age 12-23 months are most likely to be taken for treatment, and chil-
dren less than six months of age are least likely. There is little difference in the percentage of chil-
dren taken for treatment for diarrhea by childs sex and urban-rural residence. Children residing in
the mountain ecological zone (28 percent) and children from the Western and Far-western develop-
ment regions (about 30 percent) are more likely to be taken to a health facility for treatment than
children residing in the other regions.

Children of mothers with an SLC are more than twice as likely to take their sick children to a
health facility as mothers with no education.

Almost half of children with diarrhea received some sort of
oral rehydration therapy, that is, either ORS or increased fluids,
with 32 percent of children being treated with ORS and 27 percent
receiving increased fluids. Thirty-eight percent of children were
given a pill or syrup, while 7 percent receive home remedies or
other treatments. However, a large proportion of children with
diarrhea (35 percent) were not given any treatment.

Generally, therapeutic intervention increases with the in-
creasing age of the child up to 24-35 months and then declines
thereafter. Similarly the proportion of children not treated de-
creases sharply with increasing age of the child. For example, 64
percent of children under six months of age were not treated for
diarrhea, compared with 28 percent of children age 24-35 months.

ORT varies markedly by place of residence, by rural-urban
residence (from 46 percent in rural areas to 63 percent in urban
areas), by ecological zone (from 43 percent in the terai to
52 percent in the hill), and by development region (from 38 per-
cent in the Central region to 53 percent in the Mid-western region).

Children of educated mothers are also more likely to re-
ceive ORT than children of noneducated mothers.
FEEDING PRACTICE DURING DIARRHEA

It is recommended that children be given more liquids to
drink during diarrhea and that food intake not be reduced.

Table 9.18 presents the percent distribution of children under five years who had diarrhea in
the two weeks preceding the survey by feeding practices. One in three children who had diarrhea
were given the same amount of liquids, and 27 percent were given more than the usual amount.
However, one in four children were given less than their usual amount to drink and 16 percent were
not given anything to drink at all. This finding is surprising given the high intensity of educational
activities in this area during the last five years.

One in three children with diarrhea was given the same amount of food and 7 percent were
given more than the usual amount to eat. However, 44 percent of children with diarrhea were given
less than usual. Despite the substantial increase in educational activities about the importance of
maintaining food intake during diarrhea, 6 percent of children with diarrhea were not given any food.

Table 9.18 Feeding practices during
diarrhea

Percent distribution of children un-
der five years who had diarrhea in
the two weeks preceding the survey
by amount of liquids and food of-
fered compared with normal prac-
tice, Nepal 2001


Liquids/foods Percent

Amount of liquids offered
About the same 32.9
More than usual 26.6
Less than usual 23.9
Nothing to drink 16.4
Don't know 0.1

Total 100.0

Amount of food offered
About the same 32.3
More than usual 6.6
Less than usual 43.8
Stopped food 6.0
Never gave food 11.2
Don't know 0.0

Total 100.0
Number of children 1,320
Maternal and Child Health * 167

.
9.8 WOMENS STATUS AND USE OF HEALTH SERVICES

Status and self-respect of women can be a major determinant of a mothers ability to obtain
adequate health care for her children. Table 9.19 shows the percentage of children age 12-23 months
who have been fully vaccinated, the percentage of children with fever and/or symptoms of ARI, and
the percentage of children with diarrhea in the two weeks preceding the survey who were taken to a
health provider, according to the three measures of womens status.

The table shows that greater autonomy in decisionmaking is positively related to utilization
of health facilities and the likelihood that children are fully immunized, though the relationships are
not strong. For example, 71 percent of children of women who participate in five household deci-
sions are fully immunized, compared with 65 percent of children of women who have no final say in
any of the five household decisions. The data for Nepal show that children of women who believe
that wife beating is not justified for any reason are slightly more likely to be fully vaccinated and
taken to a health facility for treatment of ARI, fever, and diarrhea.

Table 9.19 Child health care by women's status
Percentage of children age 12-23 months fully vaccinated, and percentage of children under five years who
were ill with a fever, symptoms of ARI and/or diarrhea in the two weeks preceding the survey who were taken
to a health provider for treatment, by women's status indicators, Nepal 2001


Women's status indicator
Percentage
of children
age 12-23
months fully
vaccinated
1

Number
of
children
Percentage of
children with
fever and/or
symptoms of
ARI taken to a
health
provider
2


Number
of
children
Percentage
of children
with diarrhea
taken to a
health
provider
2

Number
of
children

Number of decisions in which
woman has final say
3


0 64.8 202 20.1 385 20.2 203
1-2 65.4 675 23.5 1,223 20.5 666
3-4 62.6 245 22.7 504 20.2 249
5 71.2 191 29.6 384 25.6 203

Number of reasons to refuse
sex with husband

0 * 17 (22.5) 30 * 12
1-2 (57.0) 40 15.0 73 (14.6) 38
3-4 65.6 1,256 24.0 2,393 21.5 1,270

Number of reasons wife
beating is justified

0 66.8 940 25.4 1,733 21.9 916
1-2 64.2 287 20.0 598 21.3 316
3-4 60.9 74 19.9 137 13.3 67
5 * 12 * 29 * 21

Total 65.6 1,313 23.7 2,496 21.2 1,320
Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based
on fewer than 25 unweighted cases and has been suppressed.
1
Those who have received BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine
given at birth)
2
Excludes pharmacy, shop and traditional practitioner
3
Either by herself or jointly with others


168 * Maternal and Child Health

9.9 WOMENS PERCEPTIONS OF PROBLEMS IN ACCESSING HEALTH CARE

Many factors can prevent a woman from getting medical advice or treatment for herself. In
the 2001 NDHS, women age 15-49 were asked whether various issues pose a big problem, a
small problem, or are not a problem in accessing health care for themselves when they are sick.

Table 9.20 shows that two in three women consider getting money for treatment to be a big
problem, and 57 percent mention not wanting to go to a health facility alone to be a big problem.
One in two women also considers the distance to a health facility, having to take transport, and lack
of a female provider to be big problems. Knowing where to go was a big problem for 28 percent of
women. In general, 87 percent of women mentioned that they considered accessing health care to be
a big problem for any of the specified reasons. Education and urban-rural residence are the two
background variables most likely to impact a womans perception of being able to access health care
for herself. Urban women are much less likely than rural women to cite any of the specified reasons
as being a big problem in accessing health care for themselves. Similarly, nearly twice as many
women with no education mention at least one of the specified problems as women with an SLC
level of education or above.

9.10 USE OF SMOKING TOBACCO

Tobacco smoking during pregnancy increases the risk of having a small or low birth weight
baby. Its use at other times also adversely affects womens health and may increase respiratory ill-
nesses among children. Table 9.21 shows the percentage of women who smoke cigarettes or pipes or
use tobacco and the distribution of women who smoke by the number of cigarettes smoked in the last
24 hours by background characteristics. Since more than one mode of tobacco consumption is possi-
ble, the percentage using tobacco may sum to more than 100 percent.

Nearly one in four women smoke cigarettes, while 4 percent smoke a pipe, and 6 per-
cent use some other form of tobacco. Smoking is more prevalent among older women than among
younger women, in rural areas than in urban areas, and in the mountain ecological zone and Mid-
western development region than in the other regions. Education is negatively associated with smok-
ing. Women who are neither pregnant nor breastfeeding are also more likely to smoke than other
women.

One in five women who smoke reported that they consumed 10 or more cigarettes in the 24
hours preceding the survey, 16 percent smoked 6-9 cigarettes, 39 percent smoked 3-5 cigarettes, and
18 percent smoked 1-2 cigarettes. Five percent of women who usually smoke did not smoke in the
24 hours preceding the survey.
Maternal and Child Health * 169

Table 9.20 Problems in accessing health care
Percentage of women who report they have big problems in accessing health care for themselves when they are sick, by type of problem and
background characteristics, Nepal 2001


Background
characteristic
Knowing
where to
go for
treatment
Getting
permission
to go for
treatment
Getting
money for
treatment
Distance
to health
facility
Having to
take
transport
Not
wanting
to go
alone
Concern
there may
not be a
female
provider
Any of the
specified
problems
Number
of
women

Age
15-19 30.2 27.7 62.3 54.5 54.0 66.1 52.0 87.6 941
20-29 27.0 17.7 63.8 48.3 48.6 54.2 47.2 84.8 3,324
30-39 26.6 14.9 68.1 50.7 51.7 56.9 50.3 86.9 2,595
40-49 30.4 13.3 70.5 52.2 52.9 58.6 50.5 88.3 1,867

Number of living children
0 31.2 27.0 62.4 53.5 52.4 65.5 53.3 86.5 1,051
1-2 26.2 16.3 61.0 47.6 47.8 53.4 48.4 83.7 3,101
3-4 25.8 13.7 66.7 48.4 50.0 55.8 47.2 85.9 3,016
5+ 33.4 17.9 78.9 58.6 58.7 61.9 52.8 93.1 1,557

Marital status
Married 27.9 17.3 65.7 50.3 51.0 57.1 49.2 86.2 8,342
Divorced, separated, widowed 29.5 10.1 79.9 55.6 52.4 59.1 53.4 92.7 384

Residence
Urban 18.3 9.6 43.6 22.2 20.0 38.6 39.3 67.8 841
Rural 29.0 17.8 68.8 53.5 54.4 59.2 50.4 88.5 7,885

Ecological zone
Mountain 41.7 23.2 82.2 73.4 83.5 76.6 62.8 96.9 602
Hill 34.9 16.9 66.6 58.1 62.4 62.8 61.5 89.0 3,615
Terai 20.5 16.3 64.0 41.4 37.6 50.1 37.8 83.1 4,509

Development region
Eastern 32.7 21.6 67.0 48.3 48.7 58.5 61.1 87.9 2,098
Central 26.1 22.7 67.1 46.3 46.1 54.5 36.2 83.6 2,804
Western 15.4 10.2 48.7 43.7 41.1 52.2 57.2 82.6 1,771
Mid-western 46.1 7.0 79.8 68.5 70.8 66.2 40.2 92.3 1,197
Far-western 23.1 15.3 79.9 58.9 65.9 61.1 60.3 92.3 855

Subregion
Eastern Mountain 40.6 21.8 62.7 62.4 71.8 63.0 72.4 92.4 126
Central Mountain 43.3 27.3 83.3 62.8 78.5 77.0 59.5 96.5 209
Western Mountain 41.0 20.5 90.5 86.8 92.9 82.7 60.9 99.4 267
Eastern Hill 46.1 25.7 71.0 64.9 69.6 65.1 70.5 92.8 580
Central Hill 39.7 27.5 63.1 44.4 50.1 56.7 52.6 81.7 945
Western Hill 17.6 11.1 49.7 47.2 48.3 57.5 69.4 85.7 1,075
Mid-western Hill 56.0 6.4 85.3 85.3 88.2 75.8 51.4 97.5 648
Far-western Hill 18.3 10.6 85.5 66.8 78.2 67.4 64.8 96.4 368
Eastern Terai 26.4 19.8 65.7 40.1 37.9 55.3 56.1 85.4 1,393
Central Terai 16.1 19.3 67.3 45.2 39.8 50.3 23.9 83.1 1,651
Western Terai 11.9 8.8 47.2 38.2 29.9 43.9 38.2 78.0 696
Mid-western Terai 34.0 7.9 69.0 39.4 40.0 45.6 25.9 82.6 438
Far-western Terai 18.2 13.3 68.8 36.6 38.9 46.6 45.1 84.7 331

Education
No education 31.7 19.3 75.8 56.8 57.1 62.8 51.8 92.0 6,279
Primary 23.7 13.4 53.3 42.4 44.3 50.2 50.9 81.3 1,294
Some secondary 14.2 10.8 35.5 26.7 27.8 37.5 38.0 67.9 814
SLC and above 7.9 2.7 14.6 21.5 21.0 27.5 24.7 48.6 339

Employment
Not employed 24.0 19.9 51.4 36.4 32.3 52.6 37.7 75.4 1,390
Working for cash 22.8 12.4 60.2 37.3 34.7 46.4 47.8 79.9 1,061
Not working for cash 29.7 17.1 70.7 55.9 58.0 60.1 52.2 90.0 6,273

Total 27.9 17.0 66.3 50.5 51.0 57.2 49.4 86.5 8,726
Note: Total includes 2 women with missing information on employment who are not shown separately
SLC = School Leaving Certificate


170 * Maternal and Child Health

Table 9.21 Use of smoking tobacco
Percentage of women who smoke cigarettes or use tobacco and percent distribution of cigarette smokers by number of cigarettes
smoked in preceding 24 hours, according to background characteristics and maternity status, Nepal 2001


Uses tobacco Number of cigarettes


Background
characteristic Cigarettes Pipe
Other
tobacco

Does
not use
tobacco

Number
of
women 0 1-2 3-5 6-9 10+ Total
Number
of
cigarette
smokers
Age
15-19 7.3 0.9 3.2 89.8 941 11.9 25.3 43.4 10.7 8.7 100.0 68
20-34 17.0 3.0 4.6 78.6 4,751 5.5 22.0 40.3 14.9 17.3 100.0 808
35-49 37.9 6.7 8.0 53.8 3,034 4.9 15.5 38.6 16.8 24.3 100.0 1,150

Residence
Urban 13.6 0.6 3.4 83.0 841 4.0 15.1 43.4 16.3 21.2 100.0 114
Rural 24.3 4.4 5.9 69.9 7,885 5.5 18.6 39.2 15.8 21.0 100.0 1,912

Ecological zone
Mountain 34.6 12.6 8.9 56.5 602 9.2 18.5 37.5 16.1 18.7 100.0 208
Hill 27.8 4.8 5.7 66.4 3,615 6.3 18.8 40.6 14.6 19.7 100.0 1,005
Terai 18.0 2.4 5.2 77.0 4,509 3.2 17.9 38.6 17.2 23.1 100.0 814

Development region
Eastern 22.0 1.3 11.7 68.2 2,098 1.6 13.9 40.9 18.3 25.3 100.0 462
Central 23.9 1.7 3.0 73.7 2,804 3.0 13.9 40.5 19.6 22.9 100.0 670
Western 18.3 0.2 5.4 76.9 1,771 1.2 13.7 34.9 18.0 32.1 100.0 324
Mid-western 28.8 16.0 4.7 62.0 1,197 16.4 36.0 40.5 4.7 2.3 100.0 345
Far-western 26.3 10.0 1.2 71.2 855 9.0 20.9 38.0 13.2 18.9 100.0 225

Subregion
Eastern Mountain 22.1 0.0 11.2 69.4 126 1.4 19.2 39.7 17.8 21.9 100.0 28
Central Mountain 44.3 1.5 16.7 53.4 209 4.0 17.1 40.6 16.6 21.7 100.0 93
Western Mountain 32.8 27.2 1.7 52.9 267 17.1 19.7 33.6 15.1 14.5 100.0 88
Eastern Hill 28.3 0.0 18.8 55.8 580 1.3 8.1 40.1 21.5 28.9 100.0 164
Central Hill 28.8 1.9 1.8 69.2 945 5.5 17.0 44.5 14.5 18.5 100.0 272
Western Hill 21.5 0.0 4.8 74.1 1,075 1.7 10.6 32.1 20.6 35.1 100.0 231
Mid-western Hill 38.4 17.5 4.6 54.1 648 13.0 34.5 44.5 6.0 2.0 100.0 249
Far-western Hill 24.1 11.3 0.0 74.7 368 11.3 22.0 40.2 10.4 16.1 100.0 89
Eastern Terai 19.4 2.0 8.8 73.3 1,393 1.8 16.8 41.5 16.4 23.4 100.0 270
Central Terai 18.5 1.6 2.0 78.9 1,651 0.5 10.2 37.0 25.1 27.2 100.0 305
Western Terai 13.4 0.4 6.4 81.3 696 0.0 21.5 41.9 11.8 24.7 100.0 93
Mid-western Terai 15.7 4.8 6.0 78.2 438 14.5 42.7 37.5 0.8 4.4 100.0 69
Far-western Terai 23.1 8.6 1.8 72.8 331 12.7 25.4 31.3 10.2 20.4 100.0 76

Education
No education 29.4 5.5 6.3 64.2 6,279 5.6 18.1 39.4 15.7 21.2 100.0 1,849
Primary 12.2 0.7 5.9 82.8 1,294 2.0 23.0 38.3 17.8 18.8 100.0 158
Some secondary 2.3 0.0 2.5 95.2 814 * * * * * 100.0 19
SLC and above 0.2 0.0 1.0 98.8 339 * * * * * 100.0 1

Maternity status
Pregnant 16.0 2.6 5.4 78.4 751 4.4 21.9 42.3 13.4 18.0 100.0 120
Breastfeeding
(not pregnant) 20.5 4.5 5.0 74.8 3,544 6.4 22.9 39.8 13.9 17.1 100.0 726

Neither 26.6 4.0 6.3 67.1 4,431 4.8 15.3 39.0 17.2 23.7 100.0 1,180

Total 23.2 4.1 5.7 71.2 8,726 5.4 18.4 39.4 15.8 21.0 100.0 2,027
Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed.
SLC = School Leaving Certificate



Infant Feeding and Childrens and Womens Nutritional Status * 171
10
INFANT FEEDING AND CHILDRENS
AND WOMENS NUTRITIONAL STATUS


The 2001 Nepal Demographic and Health Survey (NDHS) included questions about the
nutritional status of children and their mothers, including infant feeding practices, duration and
intensity of breastfeeding, the types of complementary foods given, and whether or not a bottle with
a nipple was used. In addition, information on vitamin A supplementation was collected for children.
Mothers were also asked about their intake of iron/folic acid tablets during pregnancy and vitamin A
supplements during the two months after a pregnancy. To assess the nutritional status of all children
under the age of five and women age 15-49, anthropometric (height and weight) data were also
collected.

Infant feeding practices affect the health of both the mother and her child. They are
important determinants of childrens nutritional status and many studies have shown that
breastfeeding has beneficial effects on the nutritional status, morbidity, and mortality of young
children. Breastfeeding is also associated with longer periods of postpartum amenorrhea, which in
turn leads to longer birth intervals and lower fertility levels. A longer birth interval allows mothers
to recover fully before the next pregnancy and averts maternal depletion, which may follow births
that are too closely spaced.

Maternal nutritional status has important implications for the health of the mother as well as
that of her children. A woman who is in poor nutritional health has a greater risk of having an
adverse pregnancy outcome and is more likely to give birth to underweight babies.
10.1 INITIATION OF BREASTFEEDING

Table 10.1 shows the percentage of children born in the five years before the survey
according to breastfeeding status and the timing of initial breastfeeding, by selected background
characteristics. Breastfeeding is nearly universal in Nepal, with 98 percent of children born in the
five years preceding the survey having been breastfed at some time. The 1996 NFHS showed similar
results on the percentage breastfed. Due to the large percentage of children ever breastfed,
differentials by background characteristics are small.

Early initiation of breastfeeding is beneficial for both mothers and children. Early suckling
benefits mothers because it stimulates the release of a hormone that helps the uterus to contract. The
first breast milk is important for babies because it contains colostrum, which is highly nutritious and
rich in antibodies that protect the newborn from diseases. The early initiation of breastfeeding also
increases the bond between mother and child.

Data from the 2001 NDHS indicate that nearly one in three children born in the five years
preceding the survey are breastfed within one hour of birth. It is encouraging to note that the
percentage of children breastfed within one hour of birth has nearly doubled over the last five years;
similar data collected in the 1996 NFHS showed this percentage to be 18. Comparable data collected
in the 1991 NFHS showed that 22 percent of children were breastfed within one hour of birth
(Ministry of Health, 1993).

172 * Infant Feeding and Childrens and Womens Nutritional Status


Table 10.1 Initial breastfeeding
Percentage of children born in the five years preceding the survey who were ever breastfed, and among children ever breastfed, percentage who started
breastfeeding within one hour and within one day of birth, percentage who received a prelacteal feed, and percentage who received the first milk, by
background characteristics, Nepal 2001



Percentage who started
breastfeeding:


Background characteristic
Percentage
ever
breastfed
Number
of
children
Within 1 hour
of birth
Within 1 day
of birth
1

Percentage
who received a
prelacteal feed
2

Percentage
who received
the first milk
Number of
children ever
breastfed

Sex
Male 97.8 3,450 30.7 64.6 41.2 69.1 3,373
Female 98.3 3,528 31.5 65.3 40.5 69.3 3,467

Residence
Urban 97.0 449 34.2 72.3 39.4 72.2 436
Rural 98.1 6,529 30.9 64.4 41.0 69.0 6,404

Ecological zone
Mountain 98.7 535 34.5 91.4 16.8 65.3 528
Hill 98.6 2,873 42.3 87.2 14.8 77.9 2,833
Terai 97.5 3,570 21.4 42.8 65.7 62.8 3,479

Development region
Eastern 97.3 1,610 26.2 64.0 44.7 67.4 1,566
Central 97.6 2,310 13.2 47.6 59.7 58.5 2,254
Western 98.8 1,261 32.0 59.1 43.1 81.3 1,247
Mid-western 98.7 1,048 65.5 89.4 15.9 76.4 1,034
Far-western 98.6 749 46.5 95.3 6.7 75.6 738

Subregion
Eastern Mountain 97.9 107 37.7 90.9 23.2 81.2 105
Central Mountain 99.4 177 10.5 86.8 25.2 58.9 176
Western Mountain 98.6 251 50.2 94.9 8.2 63.1 247
Eastern Hill 96.9 533 35.0 92.8 13.2 76.5 517
Central Hill 98.6 692 24.7 89.6 17.2 72.7 682
Western Hill 99.0 683 38.1 71.1 24.1 79.8 677
Mid-western Hill 99.2 634 65.3 92.8 9.8 83.3 629
Far-western Hill 99.1 330 55.3 95.6 2.8 76.4 328
Eastern Terai 97.4 969 20.2 45.2 64.3 60.8 944
Central Terai 96.9 1,441 7.9 22.2 84.7 51.5 1,396
Western Terai 98.6 578 24.7 44.9 65.5 83.0 570
Mid-western Terai 97.9 318 66.7 82.1 28.7 70.3 311
Far-western Terai 97.7 264 37.6 93.6 12.9 77.4 258

Mother's education
No education 98.0 5,176 29.8 62.0 42.4 65.2 5,072
Primary 98.3 970 32.4 72.5 36.0 77.2 953
Some secondary 97.5 587 36.6 72.5 35.8 82.8 572
SLC and above 99.5 244 40.7 78.2 39.7 89.0 243

Assistance at delivery
Traditional birth attendant
97.6 1,633 20.6 36.5 68.0 56.2 1,594
Health professional
3
97.3 897 32.8 71.5 44.3 79.7 873
Other 98.3 3,840 35.3 73.2 31.8 72.1 3,775
No one 98.3 603 30.3 79.6 20.8 71.2 593

Place of delivery
Health facility 97.6 554 35.5 76.5 41.6 85.7 541
At home 98.1 6,202 30.9 63.8 41.0 67.7 6,084
Other 97.1 216 26.6 70.1 36.0 71.3 210

Total 98.0 6,978 31.1 64.9 40.9 69.2 6,840
Note: Total includes 5 children for whom information on assistance at delivery is missing and 6 children for whom information on place of
delivery is missing who are not shown separately. Table is based on all births whether the children are living or dead at the time of interview.
SLC = School Leaving Certificate
1
Includes children who started breastfeeding within one hour of birth.
2
Children given something other than breast milk during the first three days of life before the mother started breastfeeding regularly.
3
Doctor, nurse/auxiliary nurse midwife, health assistant/auxiliary health worker, maternal child health worker, village health worker.

Infant Feeding and Childrens and Womens Nutritional Status * 173
Two out of three babies are breastfed within one day of birth, a slight improvement over the
last five years, from 60 percent in 1996. The majority of children receive colostrum69 percent of
children are given the first milk.

There is little difference in the timing of initial breastfeeding by sex of the child. However,
more urban children are breastfed within one hour of birth and within one day of birth than rural
children. Still, a higher proportion of children in urban areas do not receive the first milk, compared
with rural children. Children living in the terai are least likely to be breastfed immediately after birth
or within one day of birth, compared with children living in the mountain and hill zones of Nepal.
This was also evident from data collected in the 1996 NFHS. Children from the Mid-western
development region are most likely to be breastfed immediately after birth. Nearly all children in the
Far-western development region are breastfed within one day of birth.

Women who have completed their SLC are slightly more likely to initiate breastfeeding
within one hour and one day of birth than women who have lower levels of education. Surprisingly,
these educated women are less likely to give the first milk to their children. There is a difference in
the timing of initial breastfeeding between children delivered by medically trained personnel and
children delivered by nonmedical personnel. Children delivered by a traditional birth attendant are
least likely to be breastfed within one hour and one day of birth. These children are also least likely
to receive the first milk. Children delivered in a health facility are more likely than children delivered
at home to be breastfed within one hour of birth and within one day of birth, and these children are
also more likely to receive the first milk.

Prelacteal feeds, that is, giving something other than breast milk to newborns before the
mothers milk flows regularly, are discouraged because they are less nutritious than breast milk, are
more susceptible to contamination, and discourage suckling. Two-fifths of the children born in the
five years preceding the survey were given prelacteal feeds. The data indicate that prelacteal feeds
are more common in the terai, where two in three children receive them, compared with about one in
seven children living in the mountain and hill zones. Three-fifths of children living in the Central
development region received prelacteal feeds, compared with only 7 percent of children living in the
Far-western region. Prelacteal feeds are also more common among children whose births were
attended by a TBA than other births.
10.2 BREASTFEEDING STATUS BY AGE OF THE CHILD

Children who received only breast milk in the 24 hours before the survey are defined as being
exclusively breastfed, and children who are fully breastfed receive only plain water in addition to
breast milk. Exclusive breastfeeding is recommended for the first six months of a childs life
because breast milk is uncontaminated and contains all the nutrients needed by children in the first
few months of life. In addition, the mothers antibodies in breast milk provide immunity to children.
Early complementary feeding is discouraged for several reasons. First, it exposes infants to
pathogens and increases their risk of infection, especially diarrheal disease. Second, it decreases
infants intake of breast milk and therefore suckling, which reduces breast milk production. Third, in
a harsh socioeconomic environment, supplementary food is often nutritionally inferior.

Information on feeding was obtained by asking mothers about the current breastfeeding status
of all children under five years of age and food (liquid or solid) given to the child during the 24 hours
prior to the survey. Even though information on breastfeeding was collected for all children born in
the five years preceding the survey, the tables on breastfeeding are restricted to children born in the
three years before the survey because most children are weaned by age three.
174 * Infant Feeding and Childrens and Womens Nutritional Status

Table 10.2 shows the percent distribution of children under three years by breastfeeding
status. Contrary to the World Health Organizations recommendation of exclusive breastfeeding for
the first six months of life, only two-thirds of children less than six months of age are exclusively
breastfed. Nearly nine in ten children less than two months of age are exclusively breastfed, while
only about half of the children continue to be exclusively breastfed by the time they are 4-5 months
old. The proportion of children exclusively breastfed declines sharply for children six months and
older when solid and mushy food become an important part of their diet. This could be because
among many cultures in Nepal, the first time solid food is given is solemnized with a formal
ceremony called Pasnee, or the rice feeding ceremony. This ceremony is considered auspicious
starting from the fifth or subsequent odd-numbered month of age for female children and the sixth or
even-numbered month of age for male children. By 6-7 months of age, 53 percent of children are
given breast milk and complementary foods. This rises to 95 percent by 12-19 months of age.


Table 10.2 Breastfeeding status by age
Percent distribution of youngest children under three years living with the mother by breastfeeding status and
percentage of children under three years using a bottle with a nipple, according to age in months, Nepal 2001


Breastfeeding and consuming:




Age in
months
Not
breast-
feeding
Exclusively
breastfed
Plain
water
only
Water-
based
liquids/
juice
Other
milk
Comple-
mentary
foods Total
Number
of
children
Percentage
using a
bottle with
a nipple
1

Number
of
children

<2
0.0 86.7 6.3 0.0 4.0 3.1 100.0 161 2.1 161
2-3 0.0 72.8 11.7 2.1 8.0 5.5 100.0 211 2.3 214
4-5 0.0 54.2 14.9 0.9 12.5 17.7 100.0 275 6.1 276
6-7 0.6 17.7 18.5 1.5 9.2 52.5 100.0 206 3.6 207
8-9 0.4 4.5 10.7 0.9 4.6 78.9 100.0 222 1.5 222
10-11 1.8 1.9 8.0 0.5 1.0 86.7 100.0 202 5.2 202
12-15 1.4 0.1 3.5 0.0 0.2 94.8 100.0 443 2.7 447
16-19 3.3 0.3 0.4 0.3 0.3 95.4 100.0 422 1.5 432
20-23 8.0 0.0 0.0 0.0 1.0 91.0 100.0 401 2.1 433
24-27 12.7 0.0 0.0 0.0 0.0 87.3 100.0 320 1.6 401
28-31 18.7 0.9 0.0 0.0 0.4 80.1 100.0 334 0.8 471
32-35 22.1 0.0 0.2 0.0 0.0 77.7 100.0 247 0.8 374

<6 0.0 68.3 11.7 1.0 8.9 10.1 100.0 648 3.9 651
6-9 0.5 10.8 14.5 1.2 6.8 66.2 100.0 428 2.5 429

Note: Breastfeeding status refers to a 24-hour period (yesterday and last night). Children classified as breastfeeding
and consuming plain water only consume no supplements. The categories of not breastfeeding, exclusively breastfed,
breastfeeding and consuming plain water, water-based liquids/juice, other milk, and complementary foods (solids
and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children
who receive breast milk and water-based liquids and who do not receive complementary foods are classified in the
water-based liquid category even though they may also get plain water. Any children who get complementary food
are classified in that category as long as they are breastfeeding as well.
1
Based on all children under three years


Infant Feeding and Childrens and Womens Nutritional Status * 175

Bottle-feeding is discouraged for very young children because of its potential negative effects
on child health. It is often associated with increased risk of illness, especially diarrheal disease,
because of the difficulty in sterilizing the nipples properly. The use of a bottle is associated with a
lessening of the intensity of breastfeeding and a consequent shortening of the period of postpartum
amenorrhea. The use of bottles with nipples is relatively rare in Nepal. Data from the 2001 NDHS
shows that only 4 percent of children under six months of age and 3 percent of children age 6-9
months are given something to drink from a bottle.
10.3 DURATION AND FREQUENCY OF BREASTFEEDING

Table 10.3 presents the duration of breastfeeding by selected background characteristics. The
estimates of mean and median duration of breastfeeding are based on current status data, that is, the
proportion of children under three years of age who were being breastfed at the time of the survey, as
opposed to retrospective data on the length of breastfeeding of older children who are no longer
breastfed.

In Nepal, the median duration of breastfeeding is 33 months. The mean duration of
breastfeeding is 29 months, an increase of one month over the last five years, according to data
collected in the 1996 NFHS.

Both the duration and frequency of breastfeeding can affect the length of postpartum
amenorrhea. Table 10.3 shows that almost all children under six months of age were breastfed six
times or more in the 24 hours preceding the survey. Breastfeeding is more frequent in the daytime
than at night, with the mean number of feeds in the daytime being eight compared with five at night.
Breastfeeding is slightly more frequent among children in the terai and among children residing in
the Central development region.
176 * Infant Feeding and Childrens and Womens Nutritional Status

Table 10.3 Median duration and frequency of breastfeeding
Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years
preceding the survey, percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in
the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Nepal 2001

Median duration (months) of breastfeeding
1
Breastfeeding children under six months
2


Background
characteristic
Any
breastfeeding
Exclusive
breastfeeding
Predominant
breastfeeding
3

Number
of
children
Percentage
breastfed 6+
times in last
24 hours
Mean
number of
day feeds
Mean
number of
night feeds
Number
of
children

Sex
Male 33.9 4.0 5.7 1,990 98.6 8.0 5.4 317
Female 31.3 4.1 5.5 2,107 96.5 7.9 5.4 331

Residence
Urban 32.1 0.8 2.6 248 100.0 (7.6) (5.4) 27
Rural 32.9 4.3 5.8 3,848 97.4 8.0 5.4 621

Ecological zone
Mountain 34.2 3.3 3.4 304 95.2 6.3 4.5 43
Hill 32.8 3.6 4.4 1,665 95.1 6.1 4.9 234
Terai 32.7 4.5 7.0 2,128 99.3 9.3 5.8 371

Development region
Eastern 32.3 3.8 6.0 946 95.0 8.1 4.7 166
Central 28.1 4.3 6.5 1,375 98.7 9.2 6.1 227
Western 33.9 3.4 4.9 712 100.0 8.1 5.2 96
Mid-western 33.9 4.9 5.2 612 98.0 6.1 5.4 82
Far-western $36.0 3.7 4.5 451 96.0 5.7 4.7 76

Subregion
Eastern Mountain 31.1 1.4 1.6 58 96.3 (6.3) (3.6) 10
Central Mountain 31.9 3.5 3.5 101 95.5 * * 12
Western Mountain $36.0 4.1 4.1 145 94.4 (5.6) (4.8) 21
Eastern Hill 29.9 1.7 2.8 299 88.6 (6.7) (4.8) 48
Central Hill 28.2 4.2 5.2 413 95.3 (5.8) (4.7) 54
Western Hill 34.5 3.7 3.7 376 100.0 (6.5) (5.1) 41
Mid-western Hill 33.0 4.2 4.6 374 96.9 (5.8) (5.4) 53
Far-western Hill 30.9 4.6 5.0 203 94.9 5.9 4.7 37
Eastern Terai 32.6 5.1 7.1 590 97.7 8.8 4.8 107
Central Terai 26.9 4.5 7.6 861 100.0 10.5 6.7 162
Western Terai 33.2 3.0 6.2 337 100.0 9.3 5.3 55
Mid-western Terai $36.0 6.3 6.6 182 100.0 * * 19
Far-western Terai $36.0 3.4 4.4 159 100.0 5.7 5.0 28

Mother's education
No education 33.0 4.6 6.1 2,980 97.6 8.0 5.4 457
Primary $36.0 3.0 3.9 584 96.5 7.5 5.1 104
Some secondary 32.3 3.1 5.0 361 97.8 7.6 5.6 56
SLC and above 28.1 2.3 3.2 171 100.0 (8.9) (5.4) 31

Total 32.8 4.1 5.6 4,096 97.5 8.0 5.4 648

Mean for all children 28.9 5.0 6.5 na na na na na
Note: Median and mean durations are based on current status. The median duration of any breastfeeding is shown as $36.0 for groups in which
the exact median cannot be calculated because the proportion of breastfeeding children does not drop below 50 percent in any age group for
children under 36 months of age. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on
fewer than 25 unweighted cases and has been suppressed.
na = Not applicable
SLC = School Leaving Certificate
1
It is assumed that non-last-born children or last-born children not living with the mother are not currently breastfeeding
2
Excludes children who do not have a valid answer on the number of times breastfed
3
Either exclusively breastfed or received breast milk and plain water, water-based liquids, and/or juice only (excludes other milk)


Infant Feeding and Childrens and Womens Nutritional Status * 177
10.4 TYPES OF COMPLEMENTARY FOODS

Information on the types of food given to children under three years in the 24 hours preceding
the survey, according to their breastfeeding status, is shown in Table 10.4. This information was
gathered for the youngest breastfeeding child below three years. If an eligible mother had two
children in this category, only the youngest child was taken into consideration. In the case of Nepal,
the introduction of other liquids such as water, juice, and food made of grains takes place earlier than
the recommended age of about six months. Among breastfeeding children under six months of age,
13 percent received milk supplements, 3 percent received other liquids, 10 percent received food
made from grains, 4 percent consumed food made with ghee/oil and butter, and less than 1 percent
consumed fruits and vegetables. Overall, 10 percent of breastfeeding children under six months of
age consumed solid or semisolid food. Even a small proportion of children under two months of age
(3 percent) were given solid or semisolid food. Breastfeeding children also consumed other milk
supplements early in life, with one in five children 4-5 months of age receiving milk supplements.


Table 10.4 Foods consumed by children in the day or night preceding the interview,
Percentage of youngest children under three years of age living with the mother who consumed specific foods in the day
or night preceding the interview, by breastfeeding status and age, Nepal 2001


Age in
months
Other
milk/
cheese/
yogurt
Other
liquids
1

Food
made
from
grains
Fruits/
vegetables
Food
made
from
roots/
tubers
Food
made
from
legumes
Meat/
fish/
liver/
poultry/
eggs
Food
made
with
ghee/oil/
fat/butter
Fruits and
vegetables
rich in
vitamin A
2

Any solid
or
semisolid
food
Number
of
children
BREASTFEEDING CHILDREN
<2 5.7 0.0 2.4 0.7 0.0 0.0 0.0 1.4 0.0 3.1 161
2-3 9.7 4.2 5.5 0.5 0.0 0.0 0.0 2.0 0.0 5.5 211
4-5 20.1 4.0 17.2 1.3 0.2 2.3 1.3 6.1 0.9 18.3 275
6-7 29.5 9.4 51.9 8.5 12.7 18.3 3.0 14.0 4.5 53.4 205
8-9 36.9 19.0 76.7 25.7 32.6 35.7 9.1 33.9 17.9 79.5 222
10-11 34.4 16.3 87.6 31.3 49.9 36.0 12.0 42.7 21.9 90.4 198
12-15 41.2 27.2 95.0 49.7 63.7 43.0 17.9 54.4 39.1 96.1 437
16-19 41.0 33.3 98.6 51.4 66.8 53.5 19.6 58.4 37.6 98.7 408
20-23 46.2 36.8 98.4 52.8 66.3 46.5 21.3 55.0 38.6 98.9 369
24-27 41.3 37.9 100.0 58.9 72.4 51.1 22.1 65.5 44.9 100.0 279
28-31 46.1 41.8 98.0 53.3 73.5 52.7 22.3 61.7 38.5 99.5 272
32-35 51.2 42.5 98.7 53.5 72.5 51.1 22.7 57.0 43.0 99.7 192

<6 13.1 3.1 9.7 0.9 0.1 1.0 0.5 3.6 0.4 10.3 648
6-9 33.4 14.4 64.8 17.5 23.0 27.4 6.2 24.4 11.5 67.0 426
NONBREASTFEEDING CHILDREN
<24 59.8 53.2 96.4 51.3 66.6 46.0 21.6 63.0 36.9 96.4 58
24-27 (55.7) (46.6) (97.0) (59.7) (81.5) (47.0) (22.5) (67.9) 47.9 (100.0) 41
28-31 53.6 46.5 96.0 60.7 61.1 50.5 23.4 61.6 45.2 96.0 62
32-35 53.3 44.0 97.6 68.0 66.4 36.9 36.1 51.7 52.9 97.6 54
Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and last night). Figures in
parentheses are based on 25-49 unweighted cases.
1
Does not include plain water
2
Includes pumpkins, carrots, green leafy vegetables, mangoes, and papayas.


178 * Infant Feeding and Childrens and Womens Nutritional Status

WHO recommends the introduction of solid food to infants around the age of six months
because by that age, breast milk by itself is no longer sufficient to maintain a childs optimal growth.
It is evident that after six months of age, there is a marked increase in the type of food given to
infants with more than half of children in the age group 6-7 months given any solid and semisolid
food. The percentage of children consuming solid and semisolid food gradually rises, and by one
year of age, nearly all children are fed solid and semisolid foods.

A majority of children (65 percent) age 6-9 months consumed food made from grains. One in
four children each consumed foods made from legumes, ghee/oil/fat and butter, and roots and tubers.
The consumption of fruits and vegetables was found to be relatively low with only 17 percent of the
children age 6-9 months consuming fruits and vegetables rich in vitamin A. Similarly, only 6 percent
of children 6-9 months of age consumed meat, fish, liver, poultry, and eggs in the previous day, all of
which are rich in body-building substances essential to good health and contain nutrients that are
important for balanced physical and mental development. The introduction of these foods in the diet
is very late and stands out to be the least consumed category of food at all ages up to 35 months.
10.5 FREQUENCY OF FOOD SUPPLEMENTATION

The nutritional requirements of young children are more likely to be met if they are fed a
variety of foods. In the 2001 NDHS, interviewers read a list of specific foods and asked mothers to
report the number of days during the last seven days her child consumed each food. For any food
consumed at least once in the last seven days, the mother was also asked for the number of times that
child had consumed the food in the 24 hours preceding the survey. Tables 10.5 and 10.6 show the
mean number of times and the mean number of days children under age three consumed specific
foods in the 24 hours preceding the survey and in the seven days before the survey, by age and
breastfeeding status.

Foods rich in vitamin A were hardly given to children in the 24 hours and seven days
preceding the survey. Children tend to consume food made from grains more often than other foods.
This is especially the case with children above 12 months of age who consumed food made from
grain every day in the preceding seven days and about three times a day. Meat, fish, liver, and
poultry are least often consumed. As expected, nonbreastfeeding children tend to consume milk
supplements more often in a day and during the week.


Infant Feeding and Childrens and Womens Nutritional Status * 179



Table 10.5 Frequency of foods consumed by children in the day or night preceding the interview
Mean number of times specific foods were consumed in the day or night preceding the interview by youngest
children under three years of age living with the mother, according to breastfeeding status and age, Nepal
2001


Age in
months
Other
milk/
cheese/
yogurt
Other
liquids
1

Food
made
from
grains
Fruits/
vegetables
Food
made
from
roots/
tubers
Food
made
from
legumes
Meat/
fish/
liver/
poultry/
eggs
Food
made
with
ghee/
oil/ fat/
butter
Fruits and
vegetables
rich in
vitamin A
2

Number
of
children

BREASTFEEDING CHILDREN
<2 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 161
2-3 0.2 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 211
4-5 0.5 0.1 0.3 0.0 0.0 0.0 0.0 0.1 0.0 275
6-7 0.6 0.2 1.1 0.1 0.2 0.3 0.0 0.2 0.1 205
8-9 0.8 0.3 1.8 0.5 0.6 0.5 0.1 0.7 0.3 222
10-11 0.9 0.3 2.3 0.5 0.9 0.6 0.2 0.9 0.3 198
12-15 1.0 0.5 2.9 0.8 1.3 0.7 0.2 1.2 0.6 437
16-19 1.0 0.6 3.1 1.0 1.4 1.0 0.3 1.4 0.6 408
20-23 1.1 0.6 3.3 0.9 1.3 0.8 0.3 1.2 0.5 369
24-27 1.0 0.7 3.4 1.1 1.4 0.9 0.3 1.6 0.7 279
28-31 1.0 0.7 3.4 1.0 1.6 1.0 0.3 1.6 0.6 272
32-35 1.2 0.8 3.5 1.0 1.5 0.9 0.3 1.4 0.7 192

<6 0.3 0.1 0.2 0.0 0.0 0.0 0.0 0.1 0.0 648
6-9 0.7 0.2 1.5 0.3 0.4 0.4 0.1 0.5 0.2 426
NONBREASTFEEDING CHILDREN
<24 2.0 1.3 3.1 1.1 1.5 0.9 0.3 1.8 0.6 58
24-27 (1.5) (0.8) (3.5) (0.9) (1.6) (1.0) (0.3) (1.7) 0.6 41
28-31 1.5 0.8 3.4 1.2 1.3 1.0 0.4 1.6 0.8 62
32-35 1.2 0.8 3.6 1.2 1.5 0.7 0.5 1.3 0.8 54
Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and last night). Figures
in parentheses are based on 25-49 unweighted cases.
1
Does not include plain water
2
Includes pumpkins, carrots, green leafy vegetables, mangoes, and papayas.

180 * Infant Feeding and Childrens and Womens Nutritional Status

Table 10.6 Frequency of foods consumed by children in preceding seven days
Mean number of days specific foods were received in the seven days preceding the interview by youngest children under three years of age living with the mother, by breastfeeding
status and age, Nepal 2001

Liquids Solid/semisolid foods Fruits and vegetables rich in vitamin A

Age in
months
Plain
water
Other
milk
Other
liquids
Food
made from
grains
Food
made from
roots/tubers
Fruits and
vegetables
not rich in
vitamin A
Food
made from
legumes
Cheese/
yogurt
Meat/fish/
liver/
poultry/
eggs
Food made
from ghee/
oil/ fat/
butter
Pumpkins/
carrots/
papayas/
mangoes
Green
leafy
vegetables
Number
of
children

BREASTFEEDING CHILDREN
<2 0.5 0.3 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 161
2-3 1.2 0.6 0.3 0.4 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 211
4-5 2.5 1.3 0.3 1.1 0.0 0.0 0.1 0.0 0.0 0.4 0.0 0.1 275
6-7 5.1 2.0 0.6 3.5 0.8 0.2 1.0 0.1 0.1 1.0 0.0 0.3 205
8-9 6.4 2.6 1.3 5.5 2.1 0.6 2.1 0.1 0.5 2.2 0.2 0.9 222
10-11 6.8 2.2 1.1 6.1 3.0 0.7 2.1 0.4 0.6 2.8 0.3 1.1 198
12-15 6.9 2.7 1.8 6.7 4.2 1.1 2.7 0.4 0.8 3.5 0.3 1.9 437
16-19 7.0 2.7 2.2 6.9 4.4 1.4 3.2 0.5 0.9 3.8 0.5 1.8 408
20-23 6.9 3.0 2.4 6.9 4.3 1.3 2.9 0.6 1.1 3.5 0.5 2.0 369
24-27 7.0 2.7 2.4 7.0 4.8 1.4 3.1 0.7 1.0 4.3 0.7 2.1 279
28-31 6.9 2.9 2.8 6.9 4.8 1.4 3.3 0.7 1.0 3.9 0.5 1.7 272
32-35 7.0 3.3 2.9 6.9 4.9 1.4 3.2 0.9 1.1 3.6 0.7 2.1 192

<6 1.6 0.8 0.2 0.6 0.0 0.0 0.1 0.0 0.0 0.2 0.0 0.0 648
6-9 5.7 2.3 1.0 4.5 1.4 0.4 1.6 0.1 0.4 1.6 0.1 0.6 426

Total 5.7 2.3 1.6 5.3 3.1 0.9 2.2 0.4 0.7 2.7 0.3 1.3 3,230
NONBREASTFEEDING CHILDREN
<24 6.7 4.1 3.3 6.7 4.2 1.7 2.7 0.8 1.2 4.0 0.3 1.9 58
24-27 (7.0) (3.6) (3.3) (6.7) (4.8) (1.5) (3.0) (1.4) (1.0) (4.1) (0.4) (2.2) 41
28-31 6.7 3.5 3.3 6.7 4.4 1.6 3.2 1.4 0.9 4.1 0.9 2.0 62
32-35 6.9 3.2 3.3 6.8 4.3 2.0 2.8 0.5 1.2 3.6 0.5 3.0 54
Note: Breastfeeding status refers to a 24-hour period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases.

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Infant Feeding and Childrens and Womens Nutritional Status * 181



Figure 10.1 indicates that the mean number of meals taken in a day increases with the age of
children after six months from one meal a day among children age 6-7 months, to two meals a day
among children 8-9 months, and to three meals a day among children 12 months and above.

0.0
0.1
0.3
1.2
1.9
2.4
2.9
3.2
3.3
3.5
3.5
3.6
0.2
1.5
3.2
3.7
3.4
3.6
0.0
0.8
<2
2-3
4-5
6-7
8-9
10-11
12-15
16-19
20-23
24-27
28-31
32-35
<6
6-9
Child's age (months)
0.0 1.0 2.0 3.0 4.0
Mean number of meals (solid/semisolid food)
Breastfed
Not breastfed
Figure 10.1 Number of Meals Consumed Per Day by
Children Under 36 Months Living with the Mother
Nepal 2001 Note: Data are not shown for groups with fewer than 25 unweighted cases.


10.6 MICRONUTRIENT INTAKE

Micronutrient deficiency is an important cause of childhood morbidity and mortality. The
poor intake of nutritious food, frequent episodes of infections and infestation of parasites are some of
the primary causes of micronutrient deficiency. Among the various strategies to overcome
micronutrient malnutrition and improve food intake, consumption of fortified food and genetically
modified food and direct supplementation are the more important interventions. The 2001 NDHS
gathered information on vitamin A intake through food as well as through direct supplementation for
children, as well as on the intake of vitamin A capsules postpartum and the consumption of iron and
folic acid tablets during pregnancy among women.
182 * Infant Feeding and Childrens and Womens Nutritional Status
Table 10.7 shows that 28 percent of children
under three years of age consumed fruits and vegetables
rich in vitamin A at least once in the seven days
preceding the survey. The consumption of fruits and
vegetables rich in vitamin A is higher among older
children than among younger children. For example,
more than two in five children age 24-35 months
consumed fruits and vegetables rich in vitamin A,
compared with about one in five children age 10-11
months. There is little gender difference or variation by
birth order in the consumption of fruits and vegetables
rich in vitamin A. Thirty-seven percent of urban children
consumed fruits and vegetables rich in vitamin A,
compared with 28 percent of rural children. Children in
the terai ecological zone are less likely to consume fruits
and vegetables rich in vitamin A than children in the
other two ecological zones. Children living in the Far-
western development region are also least likely to
consume fruits and vegetables rich in vitamin A.
Children of educated mothers are more likely to consume
fruits and vegetables rich in vitamin A than children of
mothers with no education.

An important strategy for overcoming vitamin A
deficiency in the country has been the distribution of
vitamin A capsules through the Nepal National Vitamin
A Program, which has been in place since 1993 and
covers nearly all the districts of the country.
1
During the
distribution, children 6-11 months old receive 100,000
international units (IU) and children 12-59 months
receive 200,000 IU of vitamin A. Children under six
months are not covered because most children in this age
group are breastfed and receive vitamin A through breast
milk. The vitamin A distribution in Nepal was carried
out during the months of Kartik and Baisakh in the
Nepali calendar, which roughly corresponds to October
and April in the Gregorian calendar.
2
Fieldwork spanned
recall in the two different rounds, and the data were used
to capture the most recent applicable month. Mothers of
children under five were initially asked whether they
knew about the most recent vitamin A capsule
distribution. If the respondent did not know about the
distribution, then she was asked whether someone else in
the household might know of such an event. Only in rare
cases was information on vitamin A gathered from
someone other than the respondent. A respondent was
asked whether her child received vitamin A during that
distribution. If she reported that her child did receive
vitamin A, then she was asked to describe what happened


1
Seventy-two of the 75 districts were covered by the program as of April 2001.
2
The distributions that are relevant for the 2001 NDHS fieldwork were the rounds of October 18 and 19, 2000,
and April 19 and 20, 2001.
Table 10.7 Vitamin A intake among children

Percentage of youngest children under age three living with
the mother who consumed fruits and vegetables rich in
vitamin A in the seven days preceding the survey, by
background characteristics, Nepal 2001


Background
characteristic
Consumed
fruits and
vegetables rich
in vitamin A
1

Number
of
children

Age in months



<6 0.4 648


6-9 11.4 428


10-11 22.2 202


12-23 38.4 1,266


24-35 43.2 901





Sex


Male 29.1 1,677


Female 27.4 1,768





Birth order


1 29.5 798


2-3 27.7 1,396


4-5 27.5 758


6+ 28.6 493





Breastfeeding status


Breastfeeding 27.1 3,230


Not breastfeeding 45.5 215





Residence


Urban 37.2 221


Rural 27.6 3,224





Ecological zone


Mountain 37.9 253


Hill 30.2 1,414


Terai 25.3 1,778





Development region


Eastern 32.5 792


Central 26.2 1,148


Western 28.8 607


Mid-western 28.0 520


Far-western 24.6 378





Subregion


Eastern Mountain 37.4 47


Central Mountain 37.3 88


Western Mountain 38.5 118


Eastern Hill 45.3 248


Central Hill 35.2 357


Western Hill 31.5 324


Mid-western Hill 22.7 314


Far-western Hill 8.7 171


Eastern Terai 25.7 497


Central Terai 20.3 704


Western Terai 25.7 283


Mid-western Terai 36.8 159


Far-western Terai 35.5 135





Mother's education


No education 26.2 2,486


Primary 34.3 495


Some secondary 33.2 311


SLC and above 31.9 152





Mother's age at birth


<20 29.9 602


20-24 25.8 1,170


25-29 28.0 852


30-34 32.5 492


35-49 27.9 329





Total 28.2 3,445


SLC = School Leaving Certificate

1
Includes pumpkins, carrots, green leafy vegetables,
mangoes, and papayas.

Infant Feeding and Childrens and Womens Nutritional Status * 183



during the event. Interviewers were instructed to circle a spontaneous response if a respondent
mentioned that the child received a red capsule, the capsule was cut, the childs name was written
down, and the capsule was provided at a central location. If any one of these four descriptions was
not mentioned spontaneously, the respondent was probed

Table 10.8 shows coverage levels of vitamin A supplementation among children 6-59 months
of age. Overall, 81 percent of children age 6-59 months received vitamin A supplementation during
the most recent distribution. The 1998 NMSS showed that 87 percent of children age 6-59 months
received vitamin A supplementation in the most recent distribution preceding the survey. In
addition, minisurveys conducted by the Nepal Technical Assistance Group (NTAG) after every
round of the distribution have shown coverage ranging from 86 percent to above 95 percent (NTAG,
2001). Among children who received vitamin A supplementation, the four specific descriptive
conditions on vitamin A mentioned above were recounted spontaneously by mothers of 10 percent of
children, whereas in the case of 81 percent of children, this information was obtained through
probing.

Children 12-59 months are more likely to receive vitamin A supplementation than younger
children. With the exception of children in the age groups 6-9 months and 10-11 months, there is
little difference in vitamin A supplementation by age. It is possible that the low level of coverage
(44 percent) for children 6-9 months could be because some children were under six months of age
and thus ineligible during the last distribution. The DHS does not ask the age of the child during the
vitamin A distribution but rather takes into account the age on the day of the interview. The
inclusion of these ineligible children may lead to some slight underestimation in the coverage.

There is little difference in vitamin A supplementation by sex of the child. The urban-rural
difference in vitamin A intake is more obvious, with rural children somewhat more likely to receive
vitamin A capsules than urban children. Four out of five children in rural areas received vitamin A
capsules, compared with three in four children in urban areas. Differences by ecological zone are
minimal. Children residing in the Western region are somewhat more likely to have received vitamin
A supplementation, especially children living in the Western hill, Western terai, and Far-western
terai subregions. Vitamin A supplementation for children increases slightly with education of
mothers. These differences are consistent with findings from the NMSS 1998 and also with the
minisurveys conducted by NTAG.

A mothers nutritional status during pregnancy is important both for the childs intrauterine
development and for protection against maternal morbidity and mortality. The 2001 NDHS gathered
information on whether mothers received vitamin A supplementation during the first two months
after a delivery and whether women received iron and folic acid tablets during pregnancy.
Information on the occurrence of night blindness was also collected from women. Night blindness is
an indicator of severe vitamin A deficiency, from which pregnant women are especially prone to
suffer. Since some of the reported cases of night blindness could also be attributed to vision
difficulties in general and not specific to vitamin A deficiency, it is important to make this distinction
and exclude these cases to get a more precise estimate of night blindness.



184 * Infant Feeding and Childrens and Womens Nutritional Status

Table 10.8 Vitamin A supplement
Percentage of children 6-59 months who received vitamin A supplement during the most
recent distribution, and among those who received vitamin A, the percentage of children
whose mothers mentioned, spontaneously or after probing, all four conditions of receipt
of vitamin A, by background characteristics, Nepal 2001

Among children who received
vitamin A:
Background
characteristic
Percentage
of children
who
received
vitamin A
Number
of
children
Percentage
whose mother
mentioned
all four
conditions
spontaneously
1

Percentage
whose mother
mentioned
all four
conditions
after probing
1

Number
of
children

Age in months
6-9 44.1 455 3.7 89.0 201
10-11 73.0 217 6.2 83.9 159
12-23 83.3 1,394 8.3 83.0 1,162
24-35 85.5 1,345 8.9 83.1 1,149
36-47 84.5 1,452 9.6 81.5 1,226
48-59 84.0 1,430 13.5 76.4 1,201

Sex
Male 80.9 3,119 9.6 81.0 2,522
Female 81.2 3,174 9.8 81.7 2,576

Residence
Urban 75.3 422 10.3 75.5 318
Rural 81.4 5,870 9.7 81.8 4,780

Ecological zone
Mountain 80.5 487 13.2 81.6 392
Hill 81.9 2,622 7.6 84.0 2,147
Terai 80.4 3,183 11.0 79.2 2,559

Development region
Eastern 79.5 1,440 9.1 80.6 1,146
Central 78.2 2,069 16.3 71.5 1,619
Western 86.0 1,159 9.3 81.9 997
Mid-western 83.6 958 1.9 95.0 801
Far-western 80.4 666 3.6 91.4 535

Subregion
Eastern Mountain 79.9 97 12.3 71.4 77
Central Mountain 81.1 165 22.1 75.5 134
Western Mountain 80.3 226 7.0 90.4 181
Eastern Hill 82.0 483 9.2 79.9 396
Central Hill 78.8 636 15.4 74.0 501
Western Hill 85.8 639 6.7 83.5 548
Mid-western Hill 83.2 574 1.7 94.8 478
Far-western Hill 77.4 291 1.7 91.6 225
Eastern Terai 78.1 861 8.7 82.0 673
Central Terai 77.6 1,268 15.9 69.8 984
Western Terai 86.3 520 12.5 80.1 449
Mid-western Terai 84.1 298 2.4 95.0 250
Far-western Terai 85.8 236 1.9 93.9 202

Mother's education
No education 80.2 4,688 8.4 83.2 3,758
Primary 83.3 862 12.2 78.1 718
Some secondary 83.3 529 14.2 75.0 440
SLC and above 84.9 214 16.1 71.6 181

Total 81.0 6,293 9.7 81.4 5,098
Note: Information on vitamin A supplements is based on mothers recall.
SLC = School Leaving Certificate
1
Child received a red capsule; the capsule was cut; the childs name was written down;
and the capsule was provided at a central location.


Infant Feeding and Childrens and Womens Nutritional Status * 185


Table 10.9 shows micronutrient intake among mothers and the status of night blindness
during pregnancy. Overall, 10 percent of recent mothers received a vitamin A supplement within two
months postpartum. Younger women and women with fewer children are more likely to receive
vitamin A postpartum. There is a marked difference by urban-rural residence, with 23 percent of
urban women receiving vitamin A postpartum, compared with only 9 percent of women in rural
areas. Women residing in the terai ecological zone and especially in the Far-western terai subregion
are more likely than residents of other regions to receive vitamin A postpartum. Similarly, educated
women are more likely to receive vitamin A postpartum than women with no education.

In general, 20 percent of women reported night blindness during pregnancy. When adjusted
for blindness not attributed to vitamin A deficiency during pregnancy, the data in Table 10.9 show
that 8 percent of women reported night blindness during their last pregnancy.

Iron-deficiency anemia has remained a public health problem in Nepal. To combat this
problem, the government has embarked on a program to provide 60 milligrams of iron per day to
pregnant women from the beginning of their second trimester of pregnancy through 45 days
postpartum for all pregnant women visiting health posts. In spite of this program, the 2001 NDHS
data show that more than three in four women who gave birth in the five years preceding the survey
did not take iron/folic acid tablets during their pregnancy, and 14 percent reported taking iron/folic
acid tablets for less than 60 days. Three percent of women reported taking these tablets for 60-89
days and 6 percent reported taking them for 90 days or longer. Younger women, women living in the
urban areas, and educated women are more likely to take iron/folic acid tablets than other women.
10.7 NUTRITIONAL STATUS OF CHILDREN

The nutritional status of young children reflects the level and pace of household, community,
and national development. Malnutrition is a direct result of insufficient food intake or repeated
infectious disease or a combination of both. It can result in an increased risk of illness and death and
can also result in a lower level of cognitive development.

The 2001 NDHS measured the heights and weights for all children under five years of age to
estimate their nutritional status. Anthropometry provides one of the most important indicators of
childrens nutritional status. A three-piece Shorr portable measuring board was used to measure the
height of children; children under two years were measured lying down (supine), while those over
two years were measured standing up. The weight of children was obtained to the nearest 0.1
kilogram using the UNISCALE digital scales from UNICEF. The scales were calibrated on a regular
basis in the field against standard weights. Three internationally accepted indices of physical growth
describing childrens nutritional status were constructed from combining the height, weight, and age
data: height-for-age, weight-for-height, and weight-for-age.
186 * Infant Feeding and Childrens and Womens Nutritional Status


Table 10.9 Micronutrient intake among mothers
Among women who gave birth in the five years preceding the survey, percentage who received a vitamin A dose in the first two
months after delivery, percentage who suffered from night blindness during pregnancy, and percentage who took iron/folic acid
tablets for specific numbers of days, by background characteristics, Nepal 2001


Percentage who
suffered night
blindness during
pregnancy



Number of days women took iron/folic acid tablets
during pregnancy








Background
characteristic



Received
vitamin A
dose
postpartum
1
Reported Adjusted
2
None <60 60-89 90+
Don't know/
missing



Number
of
women


Mother's age at birth



<20 11.7 16.6 4.8 70.4 19.1 3.5 7.0 0.1 773
20-24 12.9 17.1 6.6 72.7 15.9 3.7 7.3 0.3 1,551
25-29 10.2 19.8 8.6 76.8 14.5 2.5 5.9 0.4 1,181
30-34 6.2 22.9 10.0 86.2 9.6 1.2 2.9 0.1 687
35-49 6.7 26.1 8.9 88.6 7.6 1.3 2.2 0.3 553

Number of children
ever born

1 15.4 13.3 4.1 63.2 19.3 4.5 12.7 0.3 993
2-3 10.8 18.1 7.2 74.7 16.1 3.2 5.8 0.2 1,900
4-5 8.0 22.2 8.8 84.7 11.3 1.4 2.2 0.4 1,107
6+ 5.9 27.8 11.0 90.7 6.7 1.3 1.3 0.0 746

Residence
Urban 22.8 7.1 2.9 48.8 24.3 6.3 20.1 0.5 332
Rural 9.4 20.5 7.9 79.3 13.4 2.5 4.6 0.2 4,414

Ecological zone
Mountain 4.3 36.8 8.7 85.9 10.5 1.3 2.3 0.0 361
Hill 8.3 19.5 5.5 77.8 13.3 2.5 6.2 0.2 1,979
Terai 12.9 17.1 9.0 75.3 15.5 3.2 5.7 0.3 2,405

Development region
Eastern 12.2 19.2 7.6 76.0 14.6 2.8 6.5 0.1 1,102
Central 9.7 21.4 7.8 74.9 13.7 3.6 7.3 0.5 1,535
Western 10.1 12.6 4.0 71.4 19.6 3.1 5.7 0.1 914
Mid-western 4.1 24.3 8.0 88.7 8.0 0.8 2.6 0.0 693
Far-western 17.1 21.1 12.5 81.4 13.3 1.9 3.1 0.4 502

Subregion
Eastern Mountain 7.3 14.5 3.6 83.4 10.9 0.5 5.2 0.0 74
Central Mountain 0.9 43.9 2.6 77.8 17.8 3.0 1.3 0.0 122
Western Mountain 5.6 41.5 15.3 93.0 4.9 0.3 1.7 0.0 166
Eastern Hill 8.3 21.6 2.2 80.3 12.7 3.2 3.8 0.0 347
Central Hill 13.4 19.3 1.7 71.3 12.6 3.3 12.2 0.6 484
Western Hill 7.9 11.3 3.3 69.1 19.9 3.8 7.1 0.0 521
Mid-western Hill 1.6 26.3 9.9 90.9 7.5 0.0 1.6 0.0 405
Far-western Hill 10.4 23.2 16.1 84.2 10.8 1.0 3.4 0.6 223
Eastern Terai 14.7 18.5 10.7 72.9 16.0 2.8 8.1 0.2 681
Central Terai 8.9 19.6 11.6 76.3 13.8 3.9 5.5 0.5 930
Western Terai 13.0 14.2 4.9 74.4 19.3 2.2 3.8 0.3 393
Mid-western Terai 9.4 10.7 3.2 82.4 10.1 2.5 5.0 0.0 222
Far-western Terai 30.5 13.0 5.2 72.6 20.5 3.8 2.8 0.3 179

Mother's education
No education 7.3 22.6 9.0 84.8 10.8 1.5 2.7 0.2 3,437
Primary 11.8 15.8 4.8 70.5 19.7 3.8 5.9 0.1 684
Some secondary 21.7 8.8 2.9 49.1 26.2 6.8 17.4 0.5 439
SLC and above 32.9 3.3 1.4 26.8 27.8 12.1 32.6 0.7 186

Total 10.3 19.6 7.5 77.2 14.2 2.7 5.7 0.2 4,745
Note: For women with two or more live births in the five-year period, data refer to the most recent birth.
SLC = School Leaving Certificate
1
In the first two months after delivery
2
Women who reported night blindness but did not report difficulty with vision during the day


Infant Feeding and Childrens and Womens Nutritional Status * 187



These three indices provide indications of childrens susceptibility to diseases and their
chances of survival and are expressed as standardized (Z-scores) deviation units from the median of
a reference population recommended by the World Health Organization. The use of a reference
population is based on the finding that well-nourished children in all population groups for which
data exist follow similar growth patterns before puberty and thus exhibit similar distributions of
height and weight at given ages (Martorell and Habicht, 1986). One of the most commonly used
reference populations is the international reference population defined by the U.S. National Center
for Health Statistics (NCHS) and accepted by WHO and the U.S. Centers for Disease Control and
Prevention (CDC). The reference population serves as a point of comparison, facilitating the
examination of differences in the anthropometric status of subgroups in a population and changes in
nutritional status over time. Children who fall below two standard deviations from the reference
median are regarded as malnourished, whereas children who fall three standard deviations below the
reference median are regarded as severely malnourished. Since childrens height and weight change
with age, it is suggested that height and weight be related to age and that weight be related to height,
taking the sex of the child into consideration. Each of the three indices measures somewhat different
aspects of nutritional status.

The height-for-age index provides an indicator of linear growth retardation. Children whose
height-for-age is below minus two standard deviations (-2 SD) from the median of the reference
population are considered short for their age, or stunted. Children who are below minus three
standard deviations (-3 SD) from the reference population median are severely stunted. Stunting of a
childs growth may be the result of failure to receive adequate nutrition over a long period or of the
effects of recurrent or chronic illness. Height-for-age, therefore, represents a measure of the outcome
of undernutrition in a population over a long period and does not vary appreciably with the season of
data collection.

The weight-for-height index measures body mass in relation to body length. Children whose
weight-for-height is below minus two standard deviations (-2 SD) from the median of the reference
population are too thin for their height, or wasted, while those whose weight-for-height is below
minus three standard deviations (-3 SD) from the reference population median are severely wasted.
Wasting represents the failure to receive adequate nutrition during the period immediately before the
survey. It may be the result of recent episodes of illness, especially diarrhea, or of acute food
shortage.

Weight-for-age is a composite index of height-for-age and weight-for-height. Children
whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the
reference population are underweight for their age, while those who are below minus three standard
deviations (-3 SD) from the reference population are severely underweight. Being underweight for
ones age, therefore, could mean that a child is stunted or wasted or both stunted and wasted.

Table 10.10 shows the nutritional status of children under five years classified as
malnourished according to the three indices of nutritional status, by background characteristics. The
validity of these indices is determined by several factors, including the coverage of the population of
children and the accuracy of the anthropometric measurements. The survey was not able to measure
the height and weight of all eligible children, usually because the child was not at home at the time





188 * Infant Feeding and Childrens and Womens Nutritional Status

Table 10.10 Nutritional status of children

Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age,
weight-for-height, and weight-for-age, by background characteristics, Nepal 2001


Height-for-age Weight-for-height Weight-for-age


Background
characteristic
Percentage
below
- 3 SD
Percentage
below
- 2 SD
1
Mean
z-score
(SD)
Percentage
below
- 3 SD
Percentage
below
- 2 SD
1
Mean
z-score
(SD)
Percentage
below
- 3 SD
1

Percentage
below
- 2 SD
1
Mean
z-score
(SD)
Number
of
children
Age in months



<6 1.0 9.9 -0.8 1.1 3.3 -0.2 0.9 6.7 -0.7 604


6-9 4.4 20.7 -1.2 1.0 5.9 -0.6 4.6 28.7 -1.4 423


10-11 11.0 36.5 -1.7 1.5 14.0 -1.0 18.2 54.5 -2.1 200


12-23 21.1 52.4 -2.1 3.4 22.4 -1.3 21.0 60.1 -2.2 1,308


24-35 23.1 57.2 -2.2 0.2 7.0 -1.0 16.3 56.2 -2.1 1,232


36-47 29.5 62.8 -2.3 0.3 5.9 -0.8 11.6 52.7 -2.0 1,338


48-59 27.9 60.4 -2.3 0.4 6.6 -0.8 8.8 49.1 -1.9 1,306





Sex


Male 19.0 49.2 -2.0 1.3 10.6 -0.9 10.9 46.1 -1.8 3,157


Female 23.6 51.8 -2.1 0.9 8.7 -0.9 14.2 50.5 -1.9 3,253





Birth order
2



1 16.9 46.2 -1.9 0.8 9.6 -0.8 8.7 43.3 -1.8 1,415


2-3 18.5 47.5 -1.9 1.4 10.0 -0.9 11.5 46.4 -1.8 2,549


4-5 25.1 54.5 -2.2 0.9 8.9 -0.9 14.9 52.3 -2.0 1,380


6+ 30.3 60.1 -2.3 1.3 10.3 -1.0 19.2 56.3 -2.1 891





Birth interval in months
2



First birth
3
17.1 46.2 -1.9 0.8 9.6 -0.8 8.7 43.4 -1.8 1,422


<24 26.2 56.8 -2.2 1.4 8.8 -0.9 16.4 50.2 -2.0 1,077


24-47 22.2 51.6 -2.0 1.3 9.6 -0.9 13.3 50.9 -1.9 2,796


48+ 19.2 46.7 -1.9 0.9 11.3 -0.9 12.5 46.6 -1.8 941





Size at birth
2



Very small 31.4 61.7 -2.4 0.5 10.0 -0.9 20.5 61.4 -2.2 373


Small 29.1 61.1 -2.3 1.1 14.0 -1.0 20.0 61.2 -2.2 960


Average or larger 19.1 47.7 -1.9 1.1 8.8 -0.8 10.6 44.9 -1.8 5,075


Residence


Urban 11.4 36.7 -1.6 0.6 8.2 -0.7 6.7 33.0 -1.6 426


Rural 22.0 51.5 -2.0 1.1 9.7 -0.9 13.0 49.4 -1.9 5,983





Ecological zone


Mountain 28.2 61.2 -2.3 0.9 6.2 -0.7 13.9 49.9 -1.9 488


Hill 21.5 52.7 -2.1 0.6 5.7 -0.7 10.0 45.3 -1.8 2,685


Terai 20.1 47.1 -1.9 1.6 13.4 -1.1 14.6 50.6 -2.0 3,237





Development region


Eastern 17.9 44.6 -1.8 0.8 7.8 -0.8 8.7 41.0 -1.7 1,479


Central 23.1 52.3 -2.0 1.4 12.5 -0.9 15.8 51.7 -2.0 2,098


Western 19.9 50.3 -2.0 0.9 7.0 -0.8 10.8 44.7 -1.8 1,197


Mid-western 23.2 53.8 -2.1 1.2 8.2 -0.9 12.2 52.2 -2.0 971


Far-western 23.1 53.7 -2.1 0.9 11.2 -0.9 15.1 54.6 -2.0 665





Subregion


Eastern Mountain 17.6 51.3 -2.0 0.0 1.9 -0.4 6.4 33.0 -1.6 102


Central Mountain 24.7 60.8 -2.3 0.3 5.7 -0.4 8.2 41.8 -1.7 168


Western Mountain 36.0 66.1 -2.5 1.9 8.6 -1.0 21.8 64.2 -2.3 217


Eastern Hill 18.9 48.8 -2.0 0.2 3.8 -0.6 6.5 38.4 -1.7 495


Central Hill 23.1 51.7 -2.1 0.5 3.3 -0.5 8.4 40.5 -1.7 646


Western Hill 16.6 47.9 -2.0 0.0 4.2 -0.6 7.0 39.9 -1.7 660


Mid-western Hill 25.3 59.2 -2.3 1.4 8.1 -0.9 14.4 55.8 -2.1 592


Far-western Hill 26.2 59.1 -2.2 0.6 12.6 -0.9 17.1 58.1 -2.1 292


Eastern Terai 17.3 41.4 -1.7 1.3 10.8 -0.9 10.1 43.4 -1.8 882


Central Terai 22.9 51.5 -2.0 2.0 18.1 -1.2 20.5 58.6 -2.1 1,283


Western Terai 23.9 53.3 -2.0 2.0 10.5 -1.0 15.4 50.5 -2.0 537


Mid-western Terai 14.2 37.0 -1.7 0.5 8.7 -1.0 5.2 40.8 -1.8 295


Far-western Terai 13.7 43.2 -1.8 0.7 10.7 -0.9 9.0 46.0 -1.8 240





Mother's education
4



No education 24.9 54.9 -2.1 1.3 10.8 -0.9 15.0 53.1 -2.0 4,594


Primary 13.8 43.0 -1.8 0.6 8.2 -0.8 8.3 41.0 -1.7 887


Some secondary 10.8 34.7 -1.6 0.5 5.3 -0.7 5.0 31.3 -1.5 530


SLC and above 2.4 27.9 -1.2 0.7 3.0 -0.6 0.7 21.9 -1.2 224





Mother's age
4



15-19 14.1 40.9 -1.7 1.3 9.5 -0.7 9.4 38.1 -1.6 372


20-24 18.2 45.1 -1.9 1.1 11.1 -0.9 11.7 46.3 -1.8 1,890


25-29 20.4 49.7 -2.0 1.3 9.2 -0.9 11.4 48.7 -1.9 1,981


30-34 22.8 54.9 -2.1 0.7 8.2 -0.8 13.5 48.0 -1.9 1,198


35-49 30.3 61.2 -2.3 1.1 9.6 -0.9 16.8 55.7 -2.1 968





Children of
interviewed mothers
21.3 50.5 -2.0 1.1 9.7 -0.9 12.7 48.4 -1.9 6,235





Total 21.3 50.5 -2.0 1.1 9.6 -0.9 12.6 48.3 -1.9 6,410

Note: Table is based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard deviation
units (SD) from the median of the NCHS/CDC/WHO International Reference Population. The percentage of children who are more than three or
more than two standard deviations below the median of the International Reference Population (-3 SD and -2 SD) are shown according to background
characteristics. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight.
SLC = School Leaving Certificate
1
Includes children who are below 3 standard deviations (SD) from the International Reference Population median.
2
Excludes children whose mothers were not interviewed
3
First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval.
4
For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the
household schedule.


Infant Feeding and Childrens and Womens Nutritional Status * 189






the measurements were being taken or because the mother refused to allow the child to be weighed
and measured. The survey did not measure 3 percent of children under age five (Appendix Table
C.3). In addition, children with incomplete information on month and year of birth and children with
grossly improbable height or weight measurements were excluded from the analysis (4 percent of
children). Height and weight measurements for Nepal are shown for 6,410 children age 0-59 months
at the time of the survey, for whom complete and plausible anthropometric data were collected.

An examination of Table 10.10 on height-for-age suggests that there is considerable chronic
malnutrition among Nepalese children. Overall, 51 percent of children under age five are stunted
and 21 percent are severely stunted. Data from the 1996 NFHS shows that stunting has in fact gone
up slightly from 48 percent, with little change in the percentage severely stunted. Data from the
1998 NMSS showed that 54 percent of children in the same age group were stunted and 22 percent
were severely stunted. A childs age is associated with the likelihood of stunting. Stunting increases
sharply from 10 percent among children under six months of age to 57 percent among children age
24-35 months. Female children are slightly more likely to be stunted (52 percent) or severely stunted
(24 percent) than male children (49 percent and 19 percent, respectively). Stunting is more prevalent
among children of higher birth order and children with a short birth interval. As expected, children
who were small or very small at birth are more likely to be short for their age than children who were
of average birth weight.

Children in rural areas are more likely to be stunted (52 percent) than children in urban areas
(37 percent), and children in the mountain zone are more likely to be stunted (61 percent) than
children in the hill (53 percent) and terai (47 percent) zones. This is probably because healthy food is
more readily available in the hills and terai than in the mountains. The Eastern development region
has the lowest level of stunting (45 percent).

As expected, stunting decreases with increasing level of mothers education, such that
children of mothers with no education are more likely to be stunted than children of mothers with
higher levels of education.

The weight-for-height index in Table 10.10 provides a measure of wasting or acute
malnutrition. Overall, 10 percent of children under the age of five are wasted and 1 percent are
severely wasted. The level of wasting increases from 3 percent among children under six months of
age, peaks at 22 percent among children 12-23 months of age, and then declines to 7 percent among
children age 48-59 months.

Table 10.10 shows that children living in the hills and mountains, in the Western
development region, and especially in the Eastern mountain subregion are less likely to be wasted
than other children. The differentials in wasting by mothers education are similar to those observed
for stunting.

Weight-for-age takes into account both chronic and acute undernutrition and is often used to
monitor nutritional status on a longitudinal basis. Forty-eight percent of Nepalese children are
underweight and 13 percent are severely underweight. Low weight-for-age is more common among
children more than six months old and children of higher birth order but is not strongly associated
with sex or birth interval. Differentials in the percentage of children underweight by socioeconomic
characteristics are similar to those observed for wasting.
Infant Feeding and Childrens and Womens Nutritional Status * 191






Baseline information on the nutritional status of children in the country was provided by the
1975 National Nutritional Status Survey. Surveys like the 1996 NFHS collected information on the
nutritional status of children under 36 months of age. A comprehensive study of the nutritional
status of children was also conducted in the 1998 NMSS (Ministry of Health, 1999). These studies
provide information on malnutrition among Nepalese children. Although there are variations in the
survey design, results of these studies indicate that there has hardly been a commendable
improvement in the nutritional status of children since the mid-1990s (Table 10.11).

The prevalence of undernutrition among children as indicated by the 2001 NDHS is
comparable with the findings of the 1998 NMSS and the findings of the 1996 NFHS. However, there
is slight variation, which could be partly attributed to the fact that the information on children was
collected from different age groups.



Table 10.11 Trends in nutritional status of children

Nutritional status of children based on various surveys, 1975-2001

Prevalence of undernutrition

Survey

Year

Location
Age
group
(months) Stunting
a
Wasting
b

Under-
weight
c

National Nutrition Status Survey (NNS) 1975 National 6-59 69.4
d
13.0
d
69.1
d

Nepal Family Health Survey (NFHS) 1996 National 0-36 48.4 11.2 46.9
Nepal Micronutrient Status Survey (NMSS) 1998 National 6-59 54.1 6.7 47.1
Nepal Demographic and Health Survey 2001 National 0-59 50.5 9.6 48.3

a
Percentage of children with height-for-age <-2 SD from WHO/NCHS growth reference
b
Percentage of children with weight-for-height <-2 SD from WHO/NCHS growth reference
c
Percentage of children with weight-for-age <-2 SD from WHO/NCHS growth reference
d
Data taken from WHO Global Database on Child Growth and Malnutrition, 1997


10.8 NUTRITIONAL STATUS OF WOMEN

The 2001 NDHS collected anthropometric data from all ever-married women 15-49 to assess
the nutritional status of women. Womens nutritional status is important both as an indicator of
overall health and as a predictor of pregnancy outcome for both mother and child. The basic
measures used to assess nutritional status in this report are height and weight of women and BMI,
which is an indicator that combines height and weight data. Table 10.12 shows the distribution of all
women 15-49 years by height and BMI according to selected background characteristics. Height
data are missing for less than 1 percent of women, while weight data are not shown for 11 percent of
women, for whom information was missing or incomplete or who have been excluded either because
they were pregnant at the time of the interview or had given birth within two months of the
interview.

Maternal height is an outcome of nutrition during childhood and adolescence. It is useful in
predicting the risks associated with difficult deliveries, since small stature is often associated with
small pelvis size. Short women also face increased risk of having low birth weight babies. The
height below which a woman is considered at nutritional risk is in the range of 140-150 centimeters.
The mean height of mothers measured in the 2001 NDHS is 150.2 centimeters, which is similar to
findings in the 1996 NFHS. One in seven Nepalese women is below 145 centimeters and can be
considered to be at nutritional risk.
192 * Infant Feeding and Childrens and Womens Nutritional Status






Table 10.12 Nutritional status of women by background characteristics
Among women age 15-49, mean height, percentage under 145 cm, mean body mass index (BMI), and percentage with specific BMI
levels, by background characteristics, Nepal 2001

Height BMI
1
(kg/m
2
)

Background
characteristic
Mean
height
in cm
Percent-
age
below
145 cm
Number
of
women
Mean
BMI
18.5-
24.9
(normal)
<18.5
(thin)
17.0-
18.4
(mildly
thin)
16.0-
16.9
(moder-
ately
thin)
<16.0
(severely
thin)
$25.0
(over-
weight/
obese)
25.0-29.9
(over-
weight)
$30.0
(obese)
Number
of
women

Age
15-19 150.1 15.7 936 20.1 75.6 23.2 18.0 3.9 1.3 1.2 1.1 0.1 742
20-24 150.3 15.7 1,652 20.2 73.4 23.4 18.0 4.0 1.5 3.2 3.0 0.2 1,322
25-29 150.5 14.1 1,662 20.4 71.8 23.0 15.3 5.0 2.7 5.2 4.4 0.8 1,464
30-34 150.7 13.5 1,425 20.6 66.1 26.0 18.5 5.6 2.0 7.9 7.0 0.8 1,307
35-39 150.3 13.0 1,164 20.3 62.7 28.8 17.1 7.6 4.0 8.5 7.2 1.3 1,115
40-44 150.0 15.8 1,024 20.5 59.1 30.5 17.4 6.6 6.5 10.4 8.4 2.0 1,005
45-49 148.9 21.6 830 20.1 56.1 34.8 18.7 8.6 7.5 9.1 6.8 2.2 829

Residence
Urban 150.4 13.1 834 22.3 59.1 16.8 11.6 3.4 1.9 24.1 18.9 5.1 776
Rural 150.2 15.5 7,859 20.1 67.7 27.7 18.1 6.1 3.6 4.5 4.0 0.6 7,008

Ecological zone
Mountain 149.8 17.5 601 20.6 76.5 19.2 15.0 3.0 1.3 4.3 4.0 0.3 538
Hill 150.1 15.7 3,598 20.9 76.1 16.6 13.1 2.8 0.8 7.2 6.0 1.2 3,210
Terai 150.3 14.6 4,494 19.8 58.2 35.6 21.2 8.6 5.8 6.2 5.2 0.9 4,036

Development region
Eastern 150.3 14.3 2,095 20.4 65.1 27.6 17.2 6.9 3.5 7.3 6.2 1.1 1,869
Central 149.6 18.2 2,784 20.2 62.3 30.8 19.0 6.4 5.4 7.0 5.6 1.4 2,497
Western 150.1 15.7 1,769 20.9 72.1 19.4 13.4 4.3 1.7 8.4 7.4 1.1 1,604
Mid-western 150.8 12.0 1,197 20.1 71.1 25.0 18.3 4.3 2.4 4.0 3.5 0.5 1,072
Far-western 151.2 11.6 849 19.8 69.5 28.4 20.6 6.5 1.4 2.1 1.9 0.2 741

Subregion
Eastern Mountain 150.2 17.9 126 21.7 78.6 10.1 8.8 0.6 0.6 11.4 10.4 1.0 117
Central Mountain 149.3 17.6 208 20.7 78.4 17.4 14.0 2.2 1.1 4.2 3.9 0.3 189
Western Mountain 149.9 17.3 267 19.9 73.9 25.4 18.9 4.7 1.7 0.7 0.7 0.0 232
Eastern Hill 149.5 20.2 578 20.9 82.4 12.9 10.9 1.5 0.4 4.6 4.0 0.7 498
Central Hill 149.8 17.2 935 21.7 74.1 13.1 10.7 1.5 0.9 12.8 9.6 3.2 848
Western Hill 150.1 15.7 1,073 21.3 78.0 13.1 10.0 2.7 0.4 8.9 7.9 1.0 977
Mid-western Hill 150.7 12.2 648 19.8 73.2 25.1 19.8 3.8 1.5 1.8 1.8 0.0 569
Far-western Hill 151.2 10.8 365 19.6 71.3 27.7 20.6 6.4 0.7 1.0 1.0 0.0 317
Eastern Terai 150.6 11.5 1,391 20.1 56.9 35.1 20.4 9.6 5.0 8.0 6.8 1.3 1,254
Central Terai 149.6 18.9 1,642 19.2 53.3 42.8 24.4 9.7 8.7 3.9 3.4 0.5 1,461
Western Terai 150.2 15.6 696 20.2 63.0 29.3 18.6 6.9 3.9 7.7 6.5 1.2 626
Mid-western Terai 151.4 10.0 438 20.4 67.6 24.5 16.6 4.5 3.4 7.8 6.6 1.2 406
Far-western Terai 151.7 10.3 328 19.9 65.1 31.0 20.7 7.8 2.5 3.9 3.4 0.5 289

Mother's education
No education 149.9 16.8 6,248 19.9 65.4 30.4 19.2 6.9 4.3 4.2 3.5 0.7 5,638
Primary 150.4 13.6 1,294 21.0 72.3 18.1 14.0 3.3 0.8 9.6 8.1 1.4 1,144
Some secondary 151.5 9.2 814 21.6 69.4 16.3 12.5 2.2 1.5 14.3 12.3 2.0 702
SLC and above 152.2 7.1 338 22.0 67.7 13.0 8.9 2.4 1.7 19.3 16.2 3.1 300

Total 150.2 15.3 8,694 20.3 66.9 26.7 17.4 5.8 3.4 6.5 5.5 1.0 7,784
SLC = School Leaving Certificate

1
Excludes pregnant women and women with a birth in the preceding 2 months

Infant Feeding and Childrens and Womens Nutritional Status * 193








Low pre-pregnancy weight is often associated with unfavorable pregnancy outcomes,
although maternal height must also be taken into account. The mean weight of mothers, excluding
those who were pregnant at the time of the survey or who had a birth within two months of the
interview, is 46 kilograms (data not shown). This is a slight improvement over the 1996 NFHS, in
which the mean weight of mothers was 45 kilograms.

The BMI, which utilizes both height and weight and provides a better measure of thinness
than weight alone, is defined as weight in kilograms divided by the square of the height in meters.
For the BMI, a cutoff of 18.5 has been recommended for indicating chronic energy deficiency among
nonpregnant women. The mean BMI for women in Nepal is 20.3. One in four women (27 percent)
in Nepal falls below the cutoff, indicating that the level of chronic energy deficiency in Nepal is
relatively high. The 1998 NMSS also indicates that 25 percent of women in Nepal fell below the
cutoff (BMI<18.5). According to WHO, a prevalence of more than 20 percent of women with a BMI
less than 18.5 indicates a serious public health problem (Ministry of Health, 1999).

In general, there is little variation by background characteristics in maternal height and body
mass measures among Nepalese women (Table 10.12). The percentage below 145 centimeters is
highest among women age 45-49 (22 percent). Women living in rural areas are more likely to fall
below the cutoff of 145 cm than women living in the urban areas. Women residing in the mountains,
in the Central region, and the Central terai and Eastern hill subregions are more likely to fall below
the 145 cm cutoff value than other women. Womens education is related to nutritional status;
women with some education are less likely to fall below the cutoff value. For example, 17 percent of
women with no education fall below the cutoff, while only 7 percent of women with an SLC and
higher education fall below the cutoff value. This could be because women who have had some
schooling come from a higher socioeconomic group.

Obesity among Nepalese women varies with age, and as women get older, they are more
likely to be obese. This can be observed in the 2001 NDHS findings, where more women above the
age of 40 are obese. At the same time a higher proportion of older women are also more likely to be
severely thin (<16.0). This indicates that younger women are better able to maintain their normal
body weight than women in the older age groups, presumably because they are more active, more
health conscious, and less prone to age-related illnesses.

Rural women, women living in the terai, women in the Central regions, and especially those
in the Central terai subregion are more likely than other women to have a BMI lower than 18.5. This
is consistent with findings from the 1998 NMSS (Ministry of Health, 1999).
Knowledge of HIV/AIDS * 195
11
KNOWLEDGE OF HIV/AIDS


Acquired immune deficiency syndrome (AIDS) was first recognized internationally in 1981.
As of 2000, an estimated 36 million adults and children around the world were living with the human
immunodeficiency virus (HIV) and AIDS (UNAIDS, 2000). AIDS is caused by HIV, and when in-
fected with HIV, a large proportion of people dies within 5-10 years (World Health Organization,
1992). The HIV/AIDS pandemic is one of the most serious health concerns in the world today be-
cause of the high case-fatality rate and the lack of a curative treatment or vaccines. Epidemiological
studies have identified sexual intercourse, intravenous injections, blood transfusions, and fetal trans-
missions from infected mothers as the main routes of transmission of AIDS. Studies have also indi-
cated that HIV cannot be transmitted through food, water, insect vectors, or casual contact.

The first HIV infection in Nepal was identified in 1988. The potential for the spread of HIV
in Nepal is large because of extensive use of commercial sex workers, high rates of sexually trans-
mitted diseases, low levels of condom use, and pockets of intravenous drug users. As of October
2001, a total of 533 AIDS cases and 1,564 cases of HIV infection were reported to the Ministry of
Health, National Center for AIDS and STD Control (NCASC, 2001). However, these figures are
probably grossly underestimated given the current medical and public health infrastructure and lim-
ited HIV/AIDS surveillance system in Nepal. One estimate shows approximately 34,000 cases of
HIV/AIDS infection in Nepal (UNAIDS, 2000), and another study of female sex workers with sexu-
ally transmitted diseases in Kathmandu shows a 17 percent infection rate (FHI/SACTS/USAID,
2000), while it was 50 percent among intravenous drug users (Gurubacharya, 1999). Therefore, the
risk of AIDS spreading into the general population through the sexual partners of intravenous drug
users and clients of female sex workers is large.

In light of the seriousness of the situation, the government of Nepal is committed to the pre-
vention and control of AIDS and other STDs in Nepal through a multisectoral approach. In 1987, the
Nepalese government initiated the National AIDS Prevention and Control Project (NAPCP), with
financial and technical support from the World Health Organization. The project aimed at preventing
HIV transmission through sex and blood, preventing prenatal transmission, and reducing the impact
of HIV/AIDS on individuals and families (Chin et al., 1994). Recognizing the importance of a mul-
tisectoral response to preventing the AIDS epidemic, the National AIDS Coordination Committee
(NACC) was established in 1992. It was made up of representatives from key ministries and nongov-
ernmental organizations. The NAPCP became a focal point for NACC and was responsible for coor-
dinating HIV/AIDS prevention and control programs with the various ministries. The activities of the
NAPCP were coordinated through the National Center for AIDS and STD Control (NCASC) estab-
lished in 1993. The NCASC has launched a five-year (1997-2001) Strategic Plan for HIV/AIDS in
Nepal. The activities of the NCASC include screening blood samples, conducting surveillance, gen-
erating information, providing education and communication materials, promoting condoms, coun-
seling and treating those infected with STDs, and training health workers in the clinical management
of HIV/AIDS patients.

The considerable risk of transmission of HIV among the general population, together with the
limited capacity of NCASC, resulted in the mobilization of a newly coordinated joint effort to ex-
pand the national response to contain the epidemic among drug users and their partners and female
sex workers and their clients. The Nepal HIV/AIDS Initiative Program represents the joint effort of
the government of Nepal and other multilateral and bilateral agencies. The program was designed in
2001 and is to be implemented in 2002.
196 * Knowledge of HIV/AIDS
The NDHS 2001 included a series of questions on the knowledge of and attitudes toward
AIDS. All ever-married women age 15-49 and ever-married men age 15-59 were first asked whether
they had ever heard of AIDS. Those who had heard of AIDS were questioned on their knowledge of
its transmission and prevention. Respondents were also asked whether they had used condoms for
the prevention of HIV/AIDS, their perception of the precautions a person can take to avoid AIDS,
and whether they had discussed the disease with their spouse. These results are discussed below.

11.1 KNOWLEDGE OF HIV/AIDS

Data on knowledge of AIDS is presented in Table 11.1 by background characteristics of re-
spondents. Knowledge of AIDS is much higher among men (72 percent) than among women (50
percent). Although womens knowledge of AIDS is lower than mens, the percentage of women who
have heard of AIDS has nearly doubled in the last five years from 27 percent in 1996 (Pradhan et al.,
1997). Two-fifths of women and two-thirds of men believe there is a way to avoid HIV/AIDS. Some
differences in knowledge of AIDS are observed by background characteristics of respondents.
Younger respondents, residents of urban areas, those living in the hill region, and those from the
Western development region are more likely to have heard about AIDS. Knowledge of AIDS is least
prevalent among respondents living in the Western mountain subregion. As level of education in-
creases, respondents knowledge of AIDS also increases. Knowledge of AIDS is almost universal
among respondents who have passed their SLC.

11.2 KNOWLEDGE OF HIV/AIDS PREVENTION

To get an idea of the extent of knowledge about HIV/AIDS, respondents who had heard of
AIDS were further asked whether there is anything a person can do to avoid AIDS. Table 11.2 shows
the percentage of all ever-married women and men who spontaneously mentioned various ways to
avoid contracting the disease. Fifty-eight percent of women and nearly one-third (32 percent) of men
have either not heard about AIDS or do not know whether the disease can be avoided. Three percent
of women and 2 percent of men think that there is no way to avoid HIV/AIDS.

Men are two and half times (51 percent) more likely than women (21 percent) to spontane-
ously say that AIDS can be avoided by using condoms. Thirteen percent of women and 28 percent of
men stated that the disease can be avoided by limiting the number of sexual partners, while 18 per-
cent of women and 21 percent of men believe that contracting HIV/AIDS can be prevented by avoid-
ing sex with a person who has many partners. The percentage of respondents who mentioned avoid-
ing sex with prostitutes was much higher among males (25 percent) than among females (3 percent).

Three programmatically important ways to avoid the transmission of HIV/AIDS are abstain-
ing from sex, using condoms, and limiting the number of sexual partners. Respondents knowledge
of these three programmatically important ways is presented in Table 11.3. Women are much less
knowledgeable about programmatically important ways to avoid HIV/AIDS than men. Nearly twice
as many women (62 percent) as men (33 percent) are not aware of any programmatically important
ways to avoid the disease. Four times as many men as women mentioned one way (20 percent and 5
percent, respectively), and one in three women and nearly one in two men mentioned two or three
ways to avoid HIV/AIDS. Younger respondents, those residing in urban areas, respondents living in

Knowledge of HIV/AIDS * 197
Table 11.1 Knowledge of AIDS
Percentage of women and men who have heard of AIDS and who believe there is a way to avoid
HIV/AIDS, by background characteristics, Nepal 2001

Women Men

Background
characteristic
Has
heard of
AIDS
Believes
there is a
way to
avoid
HIV/AIDS
Number
of
women
Has
heard of
AIDS
Believes
there is a
way to
avoid
HIV/AIDS
Number
of
men

Age
15-19 52.1 42.3 941 86.2 80.8 102
20-24 55.4 44.1 1,658 87.2 84.3 155
25-29 51.8 41.6 1,666 85.4 81.3 126
30-39 49.0 38.4 2,595 75.3 71.0 806
40-49 42.0 28.6 1,867 68.0 61.9 576
50-59 na na na 56.6 50.0 444

Marital status
Married 49.6 38.4 8,342 72.6 67.6 2,198
Divorced/separated/widowed 49.8 38.6 384 38.4 30.1 63

Residence
Urban 80.1 67.7 841 92.7 88.6 227
Rural 46.3 35.3 7,885 69.3 64.1 2,034

Ecological zone
Mountain 44.4 29.9 602 65.7 59.3 151
Hill 60.4 46.2 3,615 80.9 76.2 896
Terai 41.5 33.3 4,509 65.6 60.3 1,214

Development region
Eastern 57.4 44.9 2,098 68.5 62.9 583
Central 41.9 32.9 2,804 72.8 68.8 750
Western 64.4 56.0 1,771 78.8 73.9 436
Mid-western 41.2 24.0 1,197 67.3 59.9 295
Far-western 36.4 24.5 855 67.3 62.2 197

Subregion
Eastern Mountain 59.1 39.1 126 68.6 59.3 33
Central Mountain 69.6 50.4 209 86.3 84.6 59
Western Mountain 17.7 9.5 267 43.3 33.7 59
Eastern Hill 59.9 40.4 580 74.7 65.1 161
Central Hill 71.1 55.7 945 92.6 87.5 278
Western Hill 77.3 67.4 1,075 82.5 82.0 235
Mid-western Hill 35.3 19.9 648 68.6 63.0 143
Far-western Hill 29.0 15.3 368 69.6 65.8 80
Eastern Terai 56.2 47.2 1,393 65.9 62.3 389
Central Terai 21.8 17.5 1,651 57.7 54.0 413
Western Terai 44.4 38.5 696 74.4 64.5 201
Mid-western Terai 57.2 34.3 438 73.2 62.6 126
Far-western Terai 51.8 41.2 331 70.7 68.3 85

Education
No education 36.1 24.7 6,279 45.6 38.3 852
Primary 74.1 60.4 1,294 78.6 72.7 670
Some secondary 93.8 85.5 814 93.7 91.2 452
SLC and above 98.5 94.5 339 98.0 97.0 287

Total 49.6 38.4 8,726 71.7 66.5 2,261
na = Not applicable
SLC = School Leaving Certificate



198 * Knowledge of HIV/AIDS

Table 11.2 Knowledge of ways to avoid HIV/AIDS
Percentage of women and men who spontaneously mentioned ways to avoid
HIV/AIDS, Nepal 2001


Ways to avoid HIV/AIDS
Percentage
of women
Percentage
of men

Does not know of AIDS or if AIDS can be avoided 58.4 31.6

Believes no way to avoid AIDS 3.2 1.9

Does not know specific way
1
0.8 0.2

Ways to avoid HIV/AIDS
Abstain from sex 4.7 4.4
Use condoms 20.6 50.8
Limit sex to one partner/stay faithful to one partner 1.1 10.8
Limit number of sexual partners 12.9 28.1
Avoid sex with prostitutes 3.1 25.3
Avoid sex with persons who have many partners 18.1 20.8
Avoid sex with homosexuals 0.0 0.1
Avoid sex with persons who inject drugs intravenously 0.9 2.6
Avoid blood transfusions 4.7 9.8
Avoid injections 4.6 9.3
Avoid sharing razor/ blades 1.3 9.7
Avoid kissing 0.1 0.5
Avoid mosquito bites 0.3 0.5
Seek protection from traditional healer 0.0 0.2
Other 12.3 23.4

Number of women/men 8,726 2,261

1
Believes there is something a person can do to avoid AIDS, but cannot spontaneously
mention any specific way



the hill zone, and those living in the Western development region are more aware of programmati-
cally important ways of HIV/AIDS prevention than their counterparts. The relationship between re-
spondents level of education and AIDS prevention knowledge is very strong. Eighty-seven percent
of women with an SLC and above knew two or three programmatically important ways of
HIV/AIDS prevention, compared with only 19 percent of women with no education. A similar pat-
tern is observed for men.

Table 11.3 also presents data on the knowledge of specific ways to avoid HIV/AIDS. The
two specific ways presented are use of condoms and limiting the number of sexual partners. One-
third of women and three-fifths of men agree that using condoms is a way to avoid HIV/AIDS, while
37 percent of women and 54 percent of men mentioned limiting the number of sexual partners. Dif-
ferences in knowledge by background characteristics are similar to those discussed earlier.
Knowledge of HIV/AIDS * 199

Table 11.3 Knowledge of programmatically important ways to avoid HIV/AIDS
Percent distribution of women and men by knowledge of three programmatically important ways to avoid HIV/AIDS, and percentage of women and men who know of two specific ways to avoid HIV/AIDS, according
to background characteristics, Nepal 2001


Women Men


Percentage who know programmatically
important ways to avoid HIV/AIDS
Percentage who know specific
ways to avoid HIV/AIDS
Percentage who know programmatically
important ways to avoid HIV/AIDS
Percentage who know specific
ways to avoid HIV/AIDS


Background
characteristic None
1
One way
Two or three
ways Total
Use
condoms
Limit number of
sexual partners
2

Number
of
women None
1
One way
Two or three
ways Total
Use
condoms
Limit number of
sexual partners
2

Number
of
men


Age


15-19 58.5 3.8 37.7 100.0 37.9 40.8 941 17.8 25.1 57.1 100.0 78.5 56.8 102


20-24 56.2 4.4 39.4 100.0 39.8 42.4 1,658 16.1 21.6 62.3 100.0 82.1 64.4 155


25-29 59.0 4.9 36.1 100.0 36.4 40.3 1,666 17.9 29.8 52.3 100.0 79.0 55.7 126


30-39 62.2 6.2 31.5 100.0 31.7 36.8 2,595 29.1 20.8 50.0 100.0 66.6 57.2 806


40-49 72.2 6.3 21.5 100.0 21.3 27.1 1,867 38.2 17.3 44.5 100.0 57.4 52.7 576


50-59 na na na na na na na 48.4 16.7 34.9 100.0 45.1 47.9 444




Marital status


Married 62.2 5.2 32.6 100.0 32.8 36.9 8,342 32.1 20.4 47.5 100.0 63.4 54.7 2,198


Divorced/separated/widowed 61.9 9.2 28.9 100.0 29.0 36.1 384 67.1 9.8 23.1 100.0 29.1 40.8 63




Residence


Urban 33.0 8.3 58.6 100.0 59.3 64.8 841 10.1 19.8 70.1 100.0 82.7 78.9 227


Rural 65.3 5.1 29.6 100.0 29.8 33.9 7,885 35.7 20.1 44.2 100.0 60.2 51.5 2,034




Ecological zone


Mountain 70.1 5.1 24.8 100.0 24.9 29.7 602 40.2 21.5 38.3 100.0 47.6 53.2 151


Hill 54.3 7.4 38.4 100.0 38.4 44.6 3,615 23.9 20.2 55.9 100.0 71.5 60.8 896


Terai 67.5 3.8 28.7 100.0 29.0 31.7 4,509 39.1 19.8 41.2 100.0 57.7 49.6 1,214




Development region


Eastern 56.0 5.6 38.3 100.0 38.9 43.0 2,098 37.2 18.9 43.9 100.0 58.7 54.4 583


Central 67.8 4.1 28.1 100.0 28.4 31.1 2,804 30.8 18.8 50.4 100.0 63.1 58.5 750


Western 44.6 9.4 46.0 100.0 45.5 54.5 1,771 24.4 16.6 59.0 100.0 72.1 64.7 436


Mid-western 76.2 2.9 20.9 100.0 21.1 23.5 1,197 41.1 29.4 29.4 100.0 55.5 32.0 295


Far-western 75.7 4.3 20.0 100.0 20.2 23.4 855 37.3 22.0 40.7 100.0 60.3 48.5 197




Subregion


Eastern Mountain 60.9 5.5 33.6 100.0 34.5 38.2 126 38.4 22.1 39.5 100.0 53.5 48.8 33


Central Mountain 49.6 8.9 41.5 100.0 41.3 50.4 209 16.2 28.2 55.6 100.0 59.0 86.3 59


Western Mountain 90.5 1.9 7.6 100.0 7.6 9.5 267 65.4 14.4 20.2 100.0 32.7 22.1 59


Eastern Hill 59.8 7.7 32.5 100.0 33.1 39.1 580 34.2 19.6 46.2 100.0 61.7 51.7 161


Central Hill 45.5 6.9 47.6 100.0 49.2 52.1 945 11.7 21.8 66.5 100.0 79.9 73.0 278


Western Hill 33.0 11.6 55.4 100.0 53.8 66.4 1,075 17.5 9.4 73.1 100.0 79.7 78.8 235


Mid-western Hill 80.1 2.3 17.6 100.0 17.6 19.9 648 40.8 35.2 24.0 100.0 57.0 22.9 143


Far-western Hill 84.7 4.6 10.7 100.0 11.2 13.9 368 34.2 20.5 45.3 100.0 63.5 52.2 80


Eastern Terai 54.1 4.7 41.2 100.0 41.6 45.0 1,393 38.3 18.3 43.3 100.0 57.9 55.9 389


Central Terai 82.9 1.8 15.3 100.0 15.0 16.6 1,651 45.7 15.4 38.9 100.0 52.5 44.7 413


Western Terai 62.5 5.9 31.6 100.0 32.7 36.0 696 32.5 25.0 42.5 100.0 63.2 48.3 201


Mid-western Terai 66.2 4.1 29.7 100.0 30.4 32.9 438 35.3 26.8 37.8 100.0 59.3 45.2 126


Far-western Terai 59.2 5.1 35.7 100.0 35.7 39.8 331 31.1 25.1 43.9 100.0 66.7 54.1 85




Education


No education 76.0 4.8 19.2 100.0 19.2 23.4 6,279 61.0 13.4 25.6 100.0 33.9 38.5 852


Primary 40.0 6.5 53.5 100.0 53.9 58.5 1,294 27.5 24.2 48.3 100.0 67.4 56.4 670


Some secondary 14.9 7.3 77.8 100.0 78.4 83.9 814 8.4 26.8 64.8 100.0 89.3 64.8 452


SLC and above 5.5 7.3 87.3 100.0 88.9 91.0 339 2.4 19.6 78.0 100.0 93.7 79.6 287




Total 62.2 5.4 32.4 100.0 32.6 36.9 8,726 33.1 20.1 46.8 100.0 62.5 54.3 2,261


Note: Programmatically important ways are abstaining from sex, using condoms, and limiting the number of sexual partners. Abstinence from sex is measured from a spontaneous response only, and using condoms and limiting the number of
sexual partners are measured from spontaneous and probed responses.
na = Not applicable
SLC = School Leaving Certificate
1
Those who have not heard of AIDS or do not know any of the three programmatically important ways to avoid HIV/AIDS
2
Refers to limiting number of sexual partners and limiting sex to one partner/staying faithful to one partner

K
n
o
w
l
e
d
g
e

o
f

H
I
V
/
A
I
D
S


*


1
9
9

200 * Knowledge of HIV/AIDS

11.3 KNOWLEDGE OF HIV/AIDS-RELATED ISSUES

Respondents who had heard of HIV/AIDS were further asked whether a healthy- looking per-
son can have AIDS and whether HIV/AIDS can be transmitted from a mother to her child. The re-
sults are presented in Table 11.4. About two-fifths of women and three-fifths of men stated correctly
that a healthy-looking person can have the AIDS virus and that the AIDS virus can be transmitted
from a mother to her child. Older respondents and those living in rural areas are much less likely to
be informed about these two aspects of AIDS. Although there is no difference on these two aspects
of HIV/AIDS knowledge among women by current marital status, there is a substantial difference
among men. A much higher percentage of currently married men are aware of these issues than men
who are not currently married. Residents of the hill zone and the Western development region are
most aware of these two aspects of HIV/AIDS knowledge. A significant difference also exists by
respondents level of education. Awareness is significantly higher among educated respondents than
among respondents with no education.

11.4 SPOUSAL COMMUNICATION ABOUT HIV/AIDS

In the 2001 NDHS, currently married women and men who had heard of AIDS were asked
whether they have ever discussed HIV/AIDS prevention with their spouses. Table 11.5 shows that
interspousal communication on HIV/AIDS prevention is low in Nepal, with only 14 percent of
women and 23 percent of men having ever discussed HIV/AIDS prevention. Discussion is least
prevalent among the oldest group of respondents. Urban residents are twice as likely to discuss
HIV/AIDS prevention with their spouse as rural residents. Those residing in the mountains are less
likely to discuss HIV/AIDS prevention with their spouse than residents of the hills and terai. Spousal
communication on HIV/AIDS is about six times higher among respondents who have passed their
SLC than respondents with no education.
Knowledge of HIV/AIDS * 201
Table 11.4 Knowledge of HIV/AIDS-related issues
Percentage of women and men who say a healthy-looking person can have AIDS and percentage who say HIV/AIDS
can be transmitted from mother to child, by background characteristics, Nepal 2001

Women Men

Background
characteristic
Percentage
who say a
healthy-
looking person
can have AIDS
Percentage who
say HIV/AIDS
can be transmit-
ted from a
mother
to a child
Number
of
women
Percentage
who say a
healthy-
looking person
can have AIDS
Percentage who
say HIV/AIDS
can be transmit-
ted from a
mother
to a child
Number
of
men
Age
15-19 42.4 45.5 941 78.8 79.8 102
20-24 42.1 46.7 1,658 80.8 78.2 155
25-29 40.0 41.6 1,666 76.5 73.5 126
30-39 37.4 40.4 2,595 68.5 66.5 806
40-49 30.8 34.7 1,867 61.2 59.6 576
50-59 na na na 48.6 49.6 444

Marital status
Married 38.0 41.2 8,342 65.4 64.2 2,198
Divorced/separated/
widowed
36.9 40.6 384 37.0 29.1 63


Residence
Urban 64.0 67.5 841 86.3 80.8 227
Rural 35.1 38.4 7,885 62.2 61.3 2,034

Ecological zone
Mountain 31.1 34.9 602 57.2 54.3 151
Hill 46.3 50.6 3,615 74.0 72.3 896
Terai 32.1 34.5 4,509 58.6 57.7 1,214

Development region
Eastern 43.0 49.2 2,098 58.9 57.2 583
Central 32.0 34.2 2,804 66.1 66.0 750
Western 52.1 54.7 1,771 76.7 76.2 436
Mid-western 30.4 31.3 1,197 55.8 49.7 295
Far-western 26.0 30.2 855 62.4 62.1 197

Subregion
Eastern Mountain 42.1 52.4 126 55.8 61.6 33
Central Mountain 47.6 52.4 209 80.3 73.5 59
Western Mountain 13.0 13.0 267 34.6 30.8 59
Eastern Hill 42.2 50.8 580 64.5 59.7 161
Central Hill 56.6 60.8 945 85.0 84.5 278
Western Hill 61.2 66.4 1,075 80.8 81.0 235
Mid-western Hill 25.0 25.2 648 58.1 51.3 143
Far-western Hill 20.0 22.6 368 63.5 67.3 80
Eastern Terai 43.5 48.3 1,393 56.9 55.8 389
Central Terai 15.9 16.7 1,651 51.4 52.6 413
Western Terai 37.9 36.8 696 71.9 70.6 201
Mid-western Terai 43.1 45.4 438 59.5 52.6 126
Far-western Terai 38.3 46.0 331 68.9 67.9 85

Education
No education 25.6 28.7 6,279 37.1 36.8 852
Primary 57.4 62.5 1,294 70.2 69.6 670
Some secondary 79.6 83.7 814 88.9 83.7 452
SLC and above 91.7 88.7 339 95.0 94.8 287

Total 37.9 41.2 8,726 64.6 63.3 2,261
na = Not applicable
SLC = School Leaving Certificate


202 * Knowledge of HIV/AIDS


Table 11.5 Discussion of HIV/AIDS with spouse
Percent distribution of currently married women and men by whether they ever discussed HIV/AIDS prevention with their
spouse, according to background characteristics, Nepal 2001

Women Men
Background
characteristic
Has dis-
cussed
HIV/AIDS
prevention
with
spouse
Has never
discussed
HIV/AIDS
prevention
with
spouse
Has
not
heard
of
AIDS Total
Number
of
women
Has dis-
cussed
HIV/AIDS
prevention
with
spouse
Has never
discussed
HIV/AIDS
prevention
with
spouse
Has not
heard of
AIDS Total
Number
of
men

Age
15-19 11.8 39.9 48.3 100.0 930 29.6 56.6 13.8 100.0 97
20-24 17.3 38.0 44.7 100.0 1,643 31.7 55.4 12.9 100.0 154
25-29 16.2 35.5 48.4 100.0 1,625 29.0 56.4 14.6 100.0 125
30-39 14.3 34.6 51.2 100.0 2,476 24.4 51.3 24.4 100.0 795
40-49 9.3 32.4 58.3 100.0 1,668 21.7 47.6 30.6 100.0 563
50-59 na na na na na 12.8 45.3 41.9 100.0 412

Residence
Urban 22.7 57.3 20.0 100.0 792 40.8 52.3 6.8 100.0 223
Rural 13.0 33.3 53.6 100.0 7,550 20.6 49.7 29.7 100.0 1,975

Ecological zone
Mountain 10.3 34.4 55.3 100.0 573 15.8 51.5 32.7 100.0 144
Hill 15.7 44.8 39.5 100.0 3,444 24.8 57.2 18.1 100.0 869
Terai 13.1 28.4 58.5 100.0 4,325 22.0 44.4 33.6 100.0 1,185

Development region
Eastern 15.1 42.1 42.8 100.0 2,002 25.5 43.6 30.9 100.0 569
Central 10.7 31.1 58.2 100.0 2,684 22.4 51.3 26.4 100.0 732
Western 20.5 44.0 35.5 100.0 1,693 24.9 56.2 18.9 100.0 421
Mid-western 12.4 28.8 58.8 100.0 1,150 14.5 52.6 32.9 100.0 285
Far-western 10.6 26.5 62.9 100.0 813 23.0 45.8 31.2 100.0 190

Subregion
Eastern Mountain 14.5 45.2 40.3 100.0 118 22.0 47.6 30.5 100.0 31
Central Mountain 15.5 54.4 30.0 100.0 197 17.0 71.4 11.6 100.0 57
Western Mountain 4.3 14.1 81.6 100.0 258 11.1 33.3 55.6 100.0 56
Eastern Hill 11.4 48.7 39.9 100.0 552 27.7 47.2 25.1 100.0 158
Central Hill 17.9 52.9 29.2 100.0 899 25.0 67.9 7.2 100.0 270
Western Hill 22.4 55.3 22.3 100.0 1,017 30.2 55.3 14.6 100.0 227
Mid-western Hill 9.5 25.8 64.7 100.0 627 13.5 54.4 32.1 100.0 140
Far-western Hill 8.6 21.3 70.1 100.0 349 22.4 50.5 27.0 100.0 75
Eastern Terai 16.7 39.1 44.2 100.0 1,332 24.8 41.8 33.3 100.0 380
Central Terai 6.0 15.8 78.2 100.0 1,588 21.4 37.4 41.3 100.0 406
Western Terai 17.7 27.0 55.3 100.0 676 18.7 57.3 24.0 100.0 194
Mid-western Terai 19.2 37.8 42.8 100.0 417 16.8 56.6 26.6 100.0 121
Far-western Terai 15.5 37.0 47.5 100.0 313 27.4 43.0 29.6 100.0 84

Education
No education 8.0 27.8 64.2 100.0 5,970 7.9 38.6 53.4 100.0 808
Primary 20.9 53.3 25.8 100.0 1,247 19.6 59.4 21.0 100.0 660
Some secondary 34.8 58.8 6.4 100.0 793 36.1 57.9 6.0 100.0 445
SLC and above 45.5 52.9 1.6 100.0 332 50.7 47.7 1.6 100.0 284

Total 14.0 35.6 50.4 100.0 8,342 22.7 49.9 27.4 100.0 2,198
na = Not applicable
SLC = School Leaving Certificate


Knowledge of HIV/AIDS * 203

11.5 SEXUAL BEHAVIOR

Promotion of safe sex, encouraging monogamous relationships, discouraging multiple sexual
partners, and the promotion of condom use are important components of AIDS prevention programs.
Information on the sexual behavior of people is important for designing and monitoring intervention
programs to control the spread of AIDS. In the 2001 NDHS, a series of questions was asked to de-
termine the proportion of men who had sexual relationships with women other than their wives in the
past 12 months. Data presented in Table 11.6 indicate that an overwhelming majority of married
Nepalese men (98 percent) did not have sex with anyone other than their wife in the past 12 months.
Sexual intercourse outside of marriage is slightly higher among younger men age 15-24, residents of
the Far-western terai subregion, and those who had attained some secondary level of education.

11.6 KNOWLEDGE AND USE OF CONDOMS

HIV/AIDS prevention and control programs in Nepal have been promoting the use of con-
doms. Therefore, knowledge of condoms is important information from the program perspective. In
the 2001 NDHS, all currently married women and men were asked whether they knew a place where
they could get condoms. Female respondents were also asked whether they could obtain condoms by
themselves if they desired. Men who had had sexual intercourse with a woman other than their wife
in the past year were also asked whether they used a condom during the last sexual intercourse.

Most women (70 percent) and men (84 percent) know a source of condoms (Table 11.7).
Knowledge of a source of condoms varies by background characteristics of respondents. Knowledge
of a condom source is higher among women age 20-29 and men age 15-29, urban residents, women
residing in the hills and terai and men residing in the hills, residents of the Central and Western de-
velopment regions and men in the Far-western region, women living in the Mid-western terai subre-
gion and men from the Central hill subregion, and respondents with some secondary education or
higher.

Although 70 percent of women know a source for condoms, only half of them said they could
get a condom by themselves if they wanted to. Womens personal access to condoms is lowest
among the oldest age group 40-49; among women living in rural areas, the terai, and the Far-western
region; and among women with no education.
204 * Knowledge of HIV/AIDS

Table 11.6 Number of sexual partners
Percent distribution of currently married men by number of persons with
whom they had sexual intercourse in the past 12 months, excluding spouses or
cohabiting partners, according to background characteristics, Nepal 2001


Number of sexual partners
excluding spouse or cohabiting partner



Background
characteristic 0 1 2+ Total

Number
of
men

Age
15-19 95.4 4.6 0.0 100.0 97
20-24 93.4 3.1 3.4 100.0 154
25-29 95.7 2.2 2.1 100.0 125
30-39 97.4 2.0 0.6 100.0 795
40-49 99.6 0.4 0.0 100.0 563
50-59 99.4 0.5 0.1 100.0 412

Residence
Urban 97.1 2.5 0.4 100.0 223
Rural 97.8 1.5 0.7 100.0 1,975

Ecological zone
Mountain 98.4 1.0 0.6 100.0 144
Hill 97.8 1.7 0.4 100.0 869
Terai 97.5 1.6 0.8 100.0 1,185

Development region
Eastern 98.3 1.2 0.5 100.0 569
Central 97.7 1.5 0.8 100.0 732
Western 97.8 1.1 1.1 100.0 421
Mid-western 97.3 2.4 0.3 100.0 285
Far-western 96.4 3.6 0.0 100.0 190

Subregion
Eastern Mountain 97.6 1.2 1.2 100.0 31
Central Mountain 97.3 1.8 0.9 100.0 57
Western Mountain 100.0 0.0 0.0 100.0 56
Eastern Hill 99.3 0.7 0.0 100.0 158
Central Hill 97.7 2.0 0.3 100.0 270
Western Hill 97.7 1.2 1.2 100.0 227
Mid-western Hill 96.6 3.4 0.0 100.0 140
Far-western Hill 98.4 1.6 0.0 100.0 75
Eastern Terai 97.9 1.4 0.7 100.0 380
Central Terai 97.7 1.1 1.1 100.0 406
Western Terai 98.0 1.0 1.0 100.0 194
Mid-western Terai 97.7 1.6 0.7 100.0 121
Far-western Terai 93.3 6.7 0.0 100.0 84

Education
No education 99.1 0.4 0.6 100.0 808
Primary 97.6 1.8 0.6 100.0 660
Some secondary 95.8 3.3 0.8 100.0 445
SLC and above 96.9 2.2 0.9 100.0 284

Total 97.7 1.6 0.7 100.0 2,198
SLC = School Leaving Certificate

Knowledge of HIV/AIDS * 205

Table 11.7 Knowledge of source of condoms, and access to condoms
Percentage of currently married women and men who know a source for
condoms, and percentage of currently married women who could get a
condom, by background characteristics, Nepal 2001

Women Men



Background
characteristic
Knows a
source
for
condoms
Could
get a
condom
Number
of
women
Knows a
source
for
condoms
Number
of
men

Age
15-19 67.3 31.2 930 95.1 97
20-24 78.2 38.3 1,643 91.5 154
25-29 75.6 38.2 1,625 94.6 125
30-39 69.5 34.2 2,476 88.3 795
40-49 56.5 25.8 1,668 82.4 563
50-59 na na na 69.7 412

Residence
Urban 75.6 40.3 792 94.2 223
Rural 68.9 33.1 7,550 83.1 1,975

Ecological zone
Mountain 62.7 33.5 573 83.6 144
Hill 68.5 40.3 3,444 87.4 869
Terai 71.3 28.6 4,325 81.9 1,185

Development region
Eastern 70.6 40.3 2,002 81.1 569
Central 72.7 29.5 2,684 85.5 732
Western 71.9 37.9 1,693 86.2 421
Mid-western 67.8 30.6 1,150 79.9 285
Far-western 54.2 27.8 813 90.6 190

Subregion
Eastern Mountain 68.4 41.6 118 84.1 31
Central Mountain 75.1 41.8 197 92.9 57
Western Mountain 50.7 23.3 258 73.7 56
Eastern Hill 73.0 49.3 552 88.1 158
Central Hill 71.9 42.9 899 95.0 270
Western Hill 75.1 47.6 1,017 83.9 227
Mid-western Hill 62.7 26.4 627 75.9 140
Far-western Hill 43.5 23.2 349 90.5 75
Eastern Terai 69.8 36.5 1,332 77.9 380
Central Terai 72.8 20.4 1,588 78.1 406
Western Terai 67.1 23.2 676 88.9 194
Mid-western Terai 77.9 38.8 417 89.7 121
Far-western Terai 70.4 34.8 313 91.3 84

Education
No education 62.0 24.8 5,970 66.8 808
Primary 82.2 48.8 1,247 89.3 660
Some secondary 94.0 62.2 793 98.5 445
SLC and above 98.4 70.8 332 99.2 284

Total 69.5 33.8 8,342 84.2 2,198
na = Not applicable
SLC = School Leaving Certificate



206 * Knowledge of HIV/AIDS
Sexual intercourse with noncohabiting partners carries a higher risk of HIV/AIDS transmis-
sion because such relationships are usually more temporary and are often associated with exposure to
multiple sex partners. The risk of disease transmission is much higher when a condom is not used
during sexual intercourse. That is why AIDS prevention and control programs emphasize limiting
sexual partners to one and using condoms, especially with noncohabiting partners.

Table 11.8 shows the percentage of men who used a condom during their last sexual inter-
course, by type of partner and background characteristics. Condom use is less common during inter-
course with a spouse than intercourse with any partner. Only 6 percent of men used a condom dur-
ing last sexual intercourse with a spouse, compared with 45 percent of men who used a condom dur-
ing last sexual intercourse with a noncohabiting partner (data not shown). Condom use in general is
higher among men who are young; who live in urban areas; who reside in the hill and terai zones, the
Far-western region, and the Far-western terai subregion; and men who have at least an SLC level of
education.
Knowledge of HIV/AIDS * 207


Table 11.8 Use of condoms by type of partner
Among men who had sexual intercourse in the past year, percentage who used
a condom during last sexual intercourse with spouse or cohabiting partner, and
with any partner, by background characteristics, Nepal 2001


Spouse or
cohabiting partner

Any partner
1



Background
characteristic Percent Number Percent Number
Age
15-19 7.7 98 9.2 99
20-24 6.6 152 7.4 154
25-29 7.9 124 8.9 126
30-39 7.0 789 6.9 791
40-49 4.0 554 4.0 554
50-59 1.9 379 1.9 379

Marital status
Married 5.6 2,143 5.7 2,148
Divorced/separated/widowed * 4 * 8

Residence
Urban 9.4 216 9.7 218
Rural 5.2 1,931 5.3 1,938

Ecological zone
Mountain 3.2 140 3.2 141
Hill 6.3 853 6.7 858
Terai 5.4 1,154 5.4 1,156

Development region
Eastern 5.2 551 5.2 552
Central 4.8 719 4.9 721
Western 5.7 406 6.0 409
Mid-western 5.3 283 5.8 284
Far-western 10.2 189 10.4 189

Subregion
Eastern Mountain 2.5 31 2.4 31
Central Mountain 3.7 55 3.7 55
Western Mountain 3.1 55 3.1 55
Eastern Hill 4.3 153 4.3 153
Central Hill 6.6 266 6.9 268
Western Hill 7.0 220 7.6 221
Mid-western Hill 5.8 138 6.9 140
Far-western Hill 8.0 76 8.0 76
Eastern Terai 5.8 367 5.7 367
Central Terai 3.7 398 3.7 398
Western Terai 4.1 186 4.1 187
Mid-western Terai 5.4 121 5.4 121
Far-western Terai 14.5 83 15.1 83

Education
No education 2.6 772 2.5 774
Primary 5.1 650 5.2 652
Some secondary 7.3 443 7.6 445
SLC and above 12.3 282 13.1 285

Total 5.6 2,148 5.8 2,156
Note: An asterisk indicates that a figure is based on fewer than 25 un-
weighted cases and has been suppressed.
SLC = School Leaving Certificate
1
Includes noncohabiting partner


References * 209
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210 * References
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Appendix A * 211
SURVEY DESIGN APPENDIX A


A.1 INTRODUCTION

The 2001 Nepal Demographic and Health Survey (NDHS) is the sixth in a series of national-
level population and health surveys conducted in Nepal. It is the second nationally representative
comprehensive survey conducted as part of the global Demographic and Health Survey (DHS) pro-
gram, the first being the 1996 Nepal Family Health Survey (NFHS). The 2001 NDHS is the first in
the history of demographic and health surveys conducted in Nepal that included a male sample. The
2001 NDHS was carried out under the aegis of the Family Health Division of the Department of
Health Services, Ministry of Health, and was implemented by New ERA, a local research organiza-
tion, which also conducted the 1996 NFHS. ORC Macro provided technical support through its
MEASURE DHS+ project. The survey was funded by the United States Agency for International
Development (USAID) through its mission in Nepal.

A.2 SURVEY OBJECTIVES

The principal objective of the 2001 NDHS is to provide current and reliable data on fertil-
ity and family planning, infant and child mortality, childrens and womens nutritional status, the
utilization of maternal and child health services, and knowledge of HIV/AIDS. This information is
essential for informed policy decisions, planning, monitoring, and evaluation of programs on health
in general and reproductive health in particular at both the national and regional levels.

A long-term objective of the survey is to strengthen the technical capacity of the Family
Health Division of the Ministry of Health to plan, conduct, process, and analyze data from complex
national population and health surveys. The 2001 NDHS data is comparable to data collected in the
1996 NFHS and similar to survey data conducted in other developing countries. This allows for
temporal and spatial comparisons of demographic health information. The 2001 NDHS also adds to
the vast and growing international database on demographic and health variables. The inclusion of
data on men adds to the richness of this data.

A.3 SAMPLE DESIGN

The 2001 NDHS collected demographic and health information from a nationally representa-
tive sample of ever-married women and men in the reproductive age groups of 15-49 and 15-59, re-
spectively.

The primary focus of the 2001 NDHS was to provide estimates of key population and health
indicators, including fertility and mortality rates, for the country as a whole and for urban and rural
areas separately. In addition, the sample was designed to provide estimates of most key variables for
the 13 domains obtained by cross-classifying the three ecological zones (mountains, hills, and terai)
with the five development regions (Eastern, Central, Western, Mid-western, and Far-western).
1


1
Due to their small size, the mountain areas of the Western, Mid-western, and Far-western regions were combined.
212 * Appendix A

A.4 SAMPLING FRAME

The 2001 NDHS used the sampling frame provided by the list of census enumeration ar-
eas (EAs) with population and household information from the 1991 Population Census. Adminis-
tratively, Nepal is divided into 75 districts. Each district is subdivided into village development
committees (VDCs), and each VDC is divided into wards. The primary sampling unit (PSU) for the
2001 NDHS is a ward or group of wards in rural areas and subwards in urban areas. In rural areas,
the ward is small enough for a complete household listing, but in urban areas, the ward size is large.
It was therefore necessary to subdivide each urban ward into subwards. Information on the subdivi-
sion of the urban wards was obtained from the Living Standards Measurement Survey, a project
funded by the World Bank.

A.5 SAMPLE SELECTION

The sample for the survey is based on a two-stage, stratified, nationally representative
sample of households. At the first stage of sampling, 257 PSUs42 in urban areas and 215 in rural
areaswere selected using systematic sampling with probability proportional to size.
2
A complete
household listing operation was then carried out in all the selected EAs to provide a sampling frame
for the second-stage selection of households. Sketch maps were constructed to identify the relative
position of housing units in an EA to help interviewers locate selected households during fieldwork.
Table A.1 shows the sample distribution of PSUs.

Global positioning system (GPS) units were used to calculate latitude and longitude coordi-
nates for each selected ward (or subward) during the household listing stage. One latitude/longitude
coordinate was taken for the center of each settlement or community within the ward. The altitude
reading was also taken with the GPS units. The positional accuracy of the GPS readings is approxi-
mately 5 to 10 meters for latitude/longitude and approximately 30 meters for altitude. This geo-
graphic information allows the 2001 NDHS data to be integrated into a geographic information sys-
tem (GIS) along with other spatial data collected in the same localities and adds to the depth of in-
formation available from the 2001 NDHS.

At the second stage of sampling, systematic samples of 34 households per PSU on average
were selected in all the regions in order to provide statistically reliable estimates of key demographic
and health variables. However, since Nepal is predominantly rural, in order to obtain statistically
reliable estimates for urban areas, it was necessary to oversample the urban areas. As such, the total
sample is weighted and a final weighting procedure was applied to provide estimates for the different
domains and for the urban and rural areas of the country as a whole.

The survey was designed to obtain completed interviews of 8,400 ever-married women
age 15-49. In addition, all ever-married males age 15-59 in every third household were interviewed.
To take nonresponse into account, a total of 8,700 households nationwide were selected. The sample
size was allocated to each district by urban and rural areas and the numbers of PSUs were calculated
based on an average sample take (the number of ultimate sampled units in a cluster) of 34 com-
pleted interviews per PSU.

2
During fieldwork, six PSUs in the Mid-western region were dropped from the sample due to security issues,
reducing the total number of PSUs covered to 251 and reducing the number of rural PSUs to 209. This also reduced the
expected number of completed interviews to 8,170 from 8,400.
Appendix A * 213

Table A.1 Sample allocation
Expected number of completed interviews of ever-married women age
15-49 and number of primary sampling units (PSUs) in each development
region and district, by residence and ecological zone, Nepal 2001






Number of PSUs


Development
region/district
Expected
number of
completed
interviews of
ever-married
women age
15-49 Urban Rural Total


MOUNTAIN


Eastern
450

Taplejung
Sankhuwasabha
Solukhumbu
150
129
171
-
-
-
4
5
3
4
5
3


Central
Dolakha
Sindhupalchok
Rasuwa
450
165
247
38

-
-
-
4
6
1
4
6
1


Western/Mid-western/
Far-western
Jumla
Mugu
Kalikot
Humla
Bajhang
Bajura
Darchula

450
64
33
76
15
125
57
80


-
-
-
-
-
-
-

1
1
2
1
3
2
2

1
1
2
1
3
2
2



HILL

Eastern
Bhojpur
Dhankuta
Illam
Khotang
Okhaldhunga
Panchthar
Terhathum
Udayapur
600
85
51
102
90
60
83
41
88
-
-
-
-
-
-
-
1
2
2
3
3
2
2
1
3
2
2
3
3
2
2
1
4


Central
Bhaktapur
Dhading
Kathmandu
Kavrepalanchok
Lalitpur
Makawanpur
Nuwakot
Ramechhap
Sindhuli
1,000
54
105
195
148
134
121
91
72
80
2
-
8
1
2
1
-
-
-
-
3
-
3
1
3
3
2
3
2
3
8
4
3
4
3
2
3



214 * Appendix A

Table A.1 Sample allocationContinued





Number of PSUs


Development region/
district
Expected
number of
completed
interviews of
ever-married
women age
15-49 Urban Rural Total



Western
Arghakhanchi
Baglung
Gorkha
Gulmi
Kaski
Lamjung
Myagdi
Palpa
Parbat
Syangja
Tanahu

900
54
93
102
112
120
74
38
57
56
95
99


-
-
1
-
2
-
-
-
-
-
-


2
3
2
3
1
2
1
3
2
3
3


2
3
3
3
3
2
1
3
2
3
3


Mid-western
Dailekh
Pyuthan
Sallyan
Surkhet
320
57
77
85
101
1
-
-
1
2
2
3
2
3
2
3
3


Far-western
Achham
Baitadi
Dadeldhura
Doti
500
162
165
61
112
-
1
-
-
4
4
2
3
4
5
2
3

TERAI

Eastern
Jhapa
Morang
Sunsari

Saptari
Siraha
1,000
243
265
196
160
136
2
3
3
1
-
6
5
4
5
6
8
8
7
6
6


Central
Dhanusa
Mahottari
Sarlahi
Rautahat
Bara
Parsa
Chitwan
1,000
189
134
189
151
103
89
145
1
-
-
-
2
-
1
5
5
5
5
3
4
3
6
5
5
5
5
4
4


Western
Nawalparasi
Rupandehi
Kapilvastu
550
186
254
110
-
2
-
5
5
5
5
7
5


Mid-western
Banke
Bardiya
Dang
450
124
136
190
1
-
1
3
4
4
4
4
5


Far-western
Kailali
Kanchanpur
500
309
191
2
2
6
3
8
5


Total 8,170 42 209 251

Appendix A * 215
A.6 SAMPLING PROBABILITIES

The first stage of sampling in each urban or rural area of a district is done by selecting wards
(or subwards) systematically with probability proportional to size (the number of households in each
PSU according to the 1991 Population Census). The first-stage selection probability (P
1i
) is calcu-
lated as:

P
1i
= (a * M
i
) / ( M
i
)

where

a: is the number of designated PSUs to be selected in the area,

M
i
: is the number of households of the i
th
PSU according to the 1991 Population
Census,

M
i
: is the number of households in the urban or rural areas of a district
according to the 1991 Population Census.


In each selected PSU, a complete household listing operation was carried out and households
were selected in such a way as to maintain a self-weighting sample in each of the 13 domains. How-
ever, the total sample for the 2001 NDHS survey is weighted and required a final weighting adjust-
ment procedure to provide estimates for the different domains. Accordingly, if the overall sampling
fraction (f) by urban and rural areas of a district has been calculated and if c
i
is the number of house-
holds selected out of the total number of households (L
i
) listed in the i
th
selected PSU, then the self-
weighting condition is expressed as:

f = P
1i
* ( c
i
/ L
i
)

Therefore the final sample of households for selection is given by the following formula:

c
i
= ( f * L
i
) / P
1i


and the household selection interval (I
i
) is:

I
i
= L
i
/ c
i


I
i
= P
1i
/ f

A.7 QUESTIONNAIRES

The 2001 NDHS used three questionnaires: the Household Questionnaire, the Womens
Questionnaire, and the Mens Questionnaire. The content and design of the questionnaires were
based on the MEASURE DHS+ Model B Questionnaire. The questionnaires were specifically
geared toward obtaining the kind of information needed by health and family planning program
managers and policymakers. The model questionnaires were then adapted to local conditions and a
number of additional questions specific to ongoing health and family planning programs in Nepal
were added. These questionnaires were developed in English and translated into the three principal
languages in use in the country: Nepali (the national language), Bhojpuri, and Maithili. They were
then independently translated back to English and appropriate changes were made in the translation
216 * Appendix A
of questions in which the back-translated version did not compare well with the original English ver-
sion. A pretest of all three questionnaires was conducted in the three local languages in September
2000.

All usual members in a selected household and visitors who stayed there the previous night
were enumerated using the Household Questionnaire. Specifically, the Household Questionnaire
obtained information on the relationship to the head of the household, residence, sex, age, marital
status, and education of each usual resident or visitor. This information was used to identify eligible
women and men for the individual interview. Ever-married women age 15-49 in all selected house-
holds and ever-married men age 15-59 in every third selected household, whether usual residents or
visitors, were deemed eligible and were interviewed. The Household Questionnaire also obtained
information on some basic socioeconomic indicators such as the source of drinking water, the type of
toilet facilities, the ownership of a variety of consumer durable items, and the flooring material. All
eligible women and all children born since Baisakh 2052 in the Nepali calendar (which roughly cor-
responds to April 1995 in the Gregorian calendar) were weighed and measured.

The Womens Questionnaire collected information on female respondents background char-
acteristics; reproductive history; contraceptive knowledge and use; antenatal, delivery, and postnatal
care; infant feeding practices; child immunization and health; marriage; fertility preferences; atti-
tudes about family planning; husbands background characteristics; womens work; and knowledge
of HIV/AIDS.

The Mens Questionnaire collected information on the male respondents background charac-
teristics, contraceptive knowledge and use, marriage, fertility preferences, attitudes about family
planning, and knowledge of HIV/AIDS.

A.8 DATA COLLECTION AND PROCESSING

A technical advisory committee was established and chaired by the director general of the
Department of Health Services of the Ministry of Health to oversee the performance and activities of
the 2001 NDHS. The committee was made up of the director of the Family Health Division of the
Ministry of Health (vice-chairman) and other representatives from the Family Health Division, the
Planning and Foreign Aid Division, and the Child Health Division of the Ministry of Health and rep-
resentatives from the Ministry of Population and Environment, the National Planning Commission,
the National Center for AIDS and STD Control, the National Health Education Information and
Communication Center, the Parliament Secretariat, the Central Bureau of Statistics, the National
Health Research Council, the Central Department of Population Studies at Tribhuvan University,
New ERA, USAID/Nepal, and ORC Macro.

Training for the main survey was conducted in December 2000 and January 2001 in Kath-
mandu. A total of 79 field staff participated in the training. They were recruited for their language
skills, academic qualifications, and previous survey work experience. Training was conducted
mostly in Nepali, and practice sessions were conducted in all three local languages. The four-week
training consisted of instruction in general interviewing techniques and field procedures for the sur-
vey, a detailed review of the questionnaires, practice in weighing and measuring women and chil-
dren, mock interviews between participants in the classroom, and practice interviews in the field. In
addition, special lectures were given on contraceptive knowledge and practice and the various meth-
ods used in Nepal, maternal and child health, and HIV/AIDS. A two-day training on anthropometric
measurement was also given. A final selection of interviewers, editors, and supervisors was made
based on their performance during the training. Persons selected to be supervisors and editors, and
persons recruited for the quality control teams were given an additional two days of training in field
Appendix A * 217
supervision, editing and maintaining data quality in the field. At the end of the training, a total of 11
teams were constituted, comprising one male supervisor, one female editor, and one male and three
female interviewers. In addition, one quality control team made up of three highly experienced indi-
viduals was constituted.

To maintain uniform survey procedures, four manuals on different aspects of the survey were
prepared. The Interviewers Manual discussed the objectives of the NDHS, interviewing techniques,
field procedures, and general procedures for completing the questionnaires and included a detailed
discussion of the Household, Womens, and Mens Questionnaires. The manual also contained in-
formation on how to weigh and measure women and children. The Supervisors and Editors Man-
ual contained instructions on organizing and supervising fieldwork, maintaining and monitoring con-
trol sheets, and general rules for editing completed questionnaires and maintaining data quality.
Trainers were given the Training Guidelines for DHS Surveys Manual, which describes the adminis-
trative and logistical aspects of training and data quality checks. The Household Listing Manual de-
scribes the mapping and household listing procedures used in DHS surveys.

The main fieldwork started in mid-January 2001 and lasted until the end of June. Throughout
the survey, senior staff from the Ministry of Health, New ERA, USAID/Nepal, and ORC Macro
maintained constant contact with the teams through direct communication and spot checking. To
ensure high-quality data, teams were closely supervised through field visits, observations of inter-
views, and checking of completed questionnaires. In addition, the quality control team visited every
team in the field to followup on the quality of the data collected. Data quality was also ensured by
providing feedback to individual teams on the results of field check tables. These tables were com-
puter generated at regular intervals from data obtained in the completed questionnaires. These re-
sults were discussed with the teams to improve their performance.

The completed questionnaires were returned to the New ERA office in Kathmandu for data
processing. The office editing staff first checked that questionnaires for all selected households and
eligible respondents had been received from the field. In addition, the few questions that had not
been precoded (example, occupation, ethnicity) were coded at this time. The data were then entered
and edited using microcomputers and the new software CSPro, developed jointly by ORC Macro, the
U.S. Bureau of Census, and SerPro Ltda. Office editing and data processing activities were initiated
soon after the beginning of fieldwork and were completed by mid-July.

A.9 RESPONSE RATE

Information on the household and individual interviews is presented in Tables A.2.1 and
A.2.2. A total of 8,864 households were selected for the 2001 NDHS, of which 8,633 were found to
be occupied. Household interviews were completed for 8,602 households or more than 99 percent of
the occupied households. A total of 8,885 eligible women from these households and 2,353 eligible
men from every third household were identified for the individual interviews. Interviews were suc-
cessfully completed for 8,726 women and 2,261 men. The response rate for eligible women is
slightly higher than for eligible men (98 percent and 96 percent, respectively).

Response rates for women and men vary by urban-rural residence. Rural women and
especially men are slightly more likely than urban women and men to have completed an interview.
There is little difference in the response rate among women by ecological zone, but men residing in
the mountain region are more likely to have completed an interview (98 percent) than men residing
in the hills (95 percent) and terai (96 percent).
218 * Appendix A

Table A.2.1 Sample implementation: women
Percent distribution of households and eligible women by results of the household and individual
interviews, and household, eligible women and overall response rates, according to ecological zone
and urban-rural residence, Nepal 2001

Ecological zone Residence

Result
Moun-
tain Hill Terai Urban Rural Total
Selected households
Completed (C) 97.3 96.7 97.3 95.8 97.2 97.0
Household present but no com-
petent respondent at home (HP) 0.2 0.2 0.4 0.2 0.3 0.3

Refused (R) 0.0 0.1 0.0 0.2 0.0 0.0
Dwelling not found (DNF) 0.0 0.0 0.0 0.1 0.0 0.0
Household absent (HA) 0.8 1.1 0.7 1.4 0.8 0.9
Dwelling vacant/address
not a dwelling (DV) 1.7 1.5 1.4 2.2 1.4 1.5

Dwelling destroyed (DD) 0.0 0.1 0.1 0.1 0.1 0.1
Other (O) 0.0 0.3 0.0 0.1 0.1 0.1

Total 100.0 100.0 100.0 100.0 100.0 100.0
Number of sampled households 1,346 3,512 4,006 1,271 7,593 8,864
Household response rate (HRR)
1
99.8 99.7 99.5 99.6 99.6 99.6

Eligible women
Completed (EWC) 98.6 98.2 98.1 96.9 98.4 98.2
Not at home (EWNH) 0.8 1.0 1.3 1.9 1.0 1.1
Refused (EWR) 0.0 0.2 0.2 0.5 0.1 0.2
Partly completed (EWPC) 0.0 0.2 0.0 0.3 0.0 0.1
Incapacitated (EWI) 0.6 0.5 0.4 0.4 0.5 0.5

Total 100.0 100.0 100.0 100.0 100.0 100.0
Number of women 1,205 3,304 4,376 1,191 7,694 8,885
Eligible women response
rate (EWRR)
2
98.6 98.2 98.1 96.9 98.4 98.2

Overall response rate (ORR)
3
98.4 97.8 97.7 96.5 98.1 97.8

1
Using the number of households falling into specific response categories, the household response
rate (HRR) is calculated as:

100 * C

________________________________
C + HP + R + DNF

2
Using the number of eligible women falling into specific response categories, the eligible woman
response rate (EWRR) is calculated as:
100 * EWC

_____________________________________________________________
EWC + EWNH + EWR + EWPC + EWI

3
The overall response rate (ORR) is calculated as:

ORR = HRR * EWRR/100


Appendix A * 219

Table A.2.2 Sample implementation: men
Percent distribution of households and eligible men by results of the household and individual
interviews, and household, eligible men and overall response rates, according to ecological zone
and urban-rural residence, Nepal 2001

Ecological zone Residence

Result
Moun-
tain Hill Terai Urban Rural Total
Selected households
Completed (C) 98.1 98.1 98.5 97.2 98.5 98.3
Household present but no com-
petent respondent at home (HP) 0.1 0.0 0.2 0.0 0.2 0.1

Refused (R) 0.0 0.1 0.0 0.3 0.0 0.0
Dwelling not found (DNF) 0.0 0.0 0.0 0.0 0.0 0.0
Household absent (HA) 0.5 0.4 0.4 0.8 0.3 0.4
Dwelling vacant/address
not a dwelling (DV) 1.3 0.9 0.8 1.5 0.8 0.9

Dwelling destroyed (DD) 0.0 0.1 0.0 0.1 0.1 0.1
Other (O) 0.0 0.2 0.0 0.1 0.1 0.1

Total 100.0 100.0 100.0 100.0 100.0 100.0
Number of sampled households 772 2,038 2,564 754 4,620 5,374
Household response rate (HRR)
1
99.9 99.9 99.7 99.7 99.8 99.8

Eligible men
Completed (EMC) 98.4 94.7 96.4 92.4 96.7 96.1
Not at home (EMNH) 1.6 3.3 2.7 4.6 2.5 2.8
Refused (EMR) 0.0 0.6 0.0 1.5 0.0 0.2
Partly completed (EMPC) 0.0 0.2 0.1 0.3 0.1 0.1
Incapacitated (EMI) 0.0 1.1 0.7 1.2 0.7 0.8

Total 100.0 100.0 100.0 100.0 100.0 100.0
Number of men 312 837 1,204 329 2,024 2,353
Eligible men response rate (EMRR)
2
98.4 94.7 96.4 92.4 96.7 96.1

Overall response rate (ORR)
3
98.3 94.6 96.2 92.1 96.5 95.9

1
Using the number of households falling into specific response categories, the household re-
sponse rate (HRR) is calculated as:
100 * C

_________________________________
C + HP + R + DNF
2
Using the number of eligible men falling into specific response categories, the eligible man re-
sponse rate (EMRR) is calculated as:
100 * EMC

___________________________________________________________
EMC + EMNH + EMR + EMPC + EMI

3
The overall response rate (ORR) is calculated as:

ORR = HRR * EMRR/100



Appendix B * 221
SAMPLING ERRORS APPENDIX B

The estimates from a sample survey are affected by two types of errors: 1) nonsampling er-
rors and 2) sampling errors. Nonsampling errors are the results of mistakes made in implementing
data collection and data processing, such as failure to locate and interview the correct household,
misunderstanding of the questions on the part of either the interviewer or the respondent, and data
entry errors. Although numerous efforts were made during the implementation of the 2001 NDHS to
minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate sta-
tistically.

Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents
selected in the 2001 NDHS is only one of many samples that could have been selected from the same
population, using the same design and expected size. Each of these samples would yield results that
differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the
variability between all possible samples. Although the degree of variability is not known exactly, it
can be estimated from the survey results.

A sampling error is usually measured in terms of the standard error for a particular statistic
(mean, percentage, etc.), which is the square root of the variance. The standard error can be used to
calculate confidence intervals within which the true value for the population can reasonably be as-
sumed to fall. For example, for any given statistic calculated from a sample survey, the value of that
statistic will fall within a range of plus or minus two times the standard error of that statistic in 95
percent of all possible samples of identical size and design.

If the sample of respondents had been selected as a simple random sample, it would have
been possible to use straightforward formulae for calculating sampling errors. However, the 2001
NDHS sample is the result of a multistage stratified design, and consequently, it was necessary to use
more complex formulae. The computer software used to calculate sampling errors for the 2001
NDHS is the ISSA Sampling Error Module (ISSAS). This module used the Taylor linearization
method of variance estimation for survey estimates that are means or proportions. The Jackknife re-
peated replication method is used for variance estimation of more complex statistics such as fertility
and mortality rates.

The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x,
where y represents the total sample value for variable y, and x represents the total number of cases in
the group or subgroup under consideration. The variance of r is computed using the formula given
below, with the standard error being the square root of the variance:

var( ) r
f
x
m
m
z
z
m
h
h
hi
h
h i
m
h
H h
=


|
\

|
.
|

(
= =

1
1
2
2
2
1 1


in which

z
hi
= y
hi
r.x
hi
, and z
h
= y
h
r.x
h
222 * Appendix B


where h represents the stratum which varies from 1 to H,
m
h
is the total number of enumeration areas selected in the h
th
stratum,
y
hi
is the sum of the values of variable y in EA i in the h
th
stratum,
x
hi
is the sum of the number of cases in EA i in the h
th
stratum, and
f is the overall sampling fraction, which is so small that it is ignored.

The Jackknife repeated replication method derives estimates of complex rates from each of
several replications of the parent sample, and calculates standard errors for these estimates using
simple formulae. Each replication considers all but one cluster in the calculation of the estimates.
Pseudo-independent replications are thus created. In the 2001 NDHS, there were 251 nonempty
clusters (PSUs). Hence, 251 replications were created. The variance of a rate r is calculated as fol-
lows:
SE r r
k k
r r
i
k
i
2
1
2
1
1
( ) var( )
( )
( ) = =



in which
r
i
= kr (k 1 ) r
(i)


where r is the estimate computed from the full sample of 251 clusters,
r
(i)
is the estimate computed from the reduced sample of 250 clusters (i
th
cluster
excluded), and
k is the total number of clusters.

In addition to the standard error, ISSAS computes the design effect (DEFT) for each estimate,
which is defined as the ratio between the standard error using the given sample design and the stan-
dard error that would result if a simple random sample had been used. A DEFT value of 1.0 indi-
cates that the sample design is as efficient as a simple random sample, while a value greater than 1.0
indicates the increase in the sampling error due to the use of a more complex and less statistically
efficient design. ISSAS also computes the relative error and confidence limits for the estimates.

Sampling errors for the 2001 NDHS are calculated for selected variables considered to be of
primary interest. The results are presented in this appendix for the country as a whole, for urban and
rural areas, for the three ecological zones (mountains, hills, and terai), and for each of the 13 subdo-
mains in the country. For each variable, the type of statistic (mean, proportion, or rate) and the base
population are given in Table B.1. Tables B.2 to B.4 present the value of the statistic (R), its stan-
dard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT),
the relative standard error (SE/R), and the 95 percent confidence limits (R2SE) for each variable.
The DEFT is considered undefined when the standard error considering simple random sample is
zero (when the estimate is close to 0 or 1).
Appendix B * 223

In general, the relative standard error for most estimates for the country as a whole is small,
except for estimates of very small proportions. There are some differentials in the relative standard
error for the estimates of subpopulations. For example, for the variable currently using any contra-
ceptive method for currently married women age 15-49, the relative standard errors as a percentage
of the estimated mean for the whole country, for urban areas, and for rural areas are 2.8 percent,
3.2 percent, and 3.2 percent, respectively.

The confidence interval (e.g., as calculated for currently using any contraceptive method
for currently married women age 15-49) can be interpreted as follows: the overall national sample
proportion is 0.393 and its standard error is 0.011. Therefore, to obtain the 95 percent confidence
limits, one adds and subtracts twice the standard error to the sample estimate, i.e. 0.3932(0.011).
There is a high probability (95 percent) that the true average proportion of contraceptive use for cur-
rently married women age 15-49 is between 0.371 and 0.415
224 * Appendix B

Table B.1 List of selected variables for sampling errors, Nepal 2001
_____________________________________________________________________________________________________________
Variable Estimate Base Population
_____________________________________________________________________________________________________________
WOMEN
_____________________________________________________________________________________________________________
Urban Proportion Ever-married women
Literate Proportion Ever-married women
No education Proportion Ever-married women
Secondary education Proportion Ever-married women
Net attendance ratio Ratio Children 6-10 years
Currently married Proportion All women
Married before age 20 Proportion All women
Currently pregnant Proportion All women
Children ever born Mean All women
Children surviving Mean All women
Children ever born to women age 40-49 Mean All women age 40-49
Total fertility rate (3 years) Rate All women
Know any contraceptive method Proportion Currently married women
Ever used any contraceptive method Proportion Currently married women
Currently using any contraceptive method Proportion Currently married women
Currently using pill Proportion Currently married women
Currently using IUD Proportion Currently married women
Currently using injectables Proportion Currently married women
Currently using condom Proportion Currently married women
Currently using female sterilization Proportion Currently married women
Currently using periodic abstinence Proportion Currently married women
Using public sector source Proportion Current users of modern method
Want no more children Proportion Currently married women
Want to delay birth at least 2 years Proportion Currently married women
Ideal family size Mean Ever-married women
Perinatal mortality (0-4 years) Ratio Number of pregnancies of 7+ months
Neonatal mortality (0-4 years) Rate Children exposed to the risk of mortality
Postneonatal mortality (0-4 years) Rate Children exposed to the risk of mortality
Infant mortality (0-4 years) Rate Children exposed to the risk of mortality
Infant mortality (5-9 years) Rate Children exposed to the risk of mortality
Infant mortality (10-14 years) Rate Children exposed to the risk of mortality
Child mortality (0-4 years) Rate Children exposed to the risk of mortality
Under-five mortality (0-4 years) Rate Children exposed to the risk of mortality
Mothers received tetanus injection for last birth Proportion Women with at least one live birth in five years before survey
Mothers received medical assistance at delivery Proportion Births in past 5 years
1

Had diarrhoea in the 2 weeks before survey Proportion Children age 0 to 59 months
Treated with oral rehydration salts (ORS) Proportion Children with diarrhoea in two weeks before interview
Taken to a health provider Proportion Children with diarrhoea in two weeks before interview
Vaccination card seen Proportion Children 12-23 months
Received BCG vaccination Proportion Children 12-23 months
Received DPT vaccination (3 doses) Proportion Children 12-23 months
Received Polio vaccination (3 doses) Proportion Children 12-23 months
Received measles vaccination Proportion Children 12-23 months
Received vitamin A supplement Proportion Children 6-59 months
Height-for-age (-2SD) Proportion Children 0-59 months
Weight-for-height (-2SD) Proportion Children 0-59 months
Weight-for-age (-2SD) Proportion Children 0-59 months
BMI <18.5 Proportion Ever-married women
_____________________________________________________________________________________________________________
MEN
____________________________________________________________________________________

Literate Proportion Ever-married men age 15-59
No education Proportion Ever-married men age 15-59
Secondary education Proportion Ever-married men age 15-59
Currently married Proportion All men age 15-59
Knows any contraceptive method Proportion Currently married men age
Ever used any contraceptive method Proportion Currently married men age
Currently using any contraceptive method Proportion Currently married men age
Currently using pill Proportion Currently married men age
Currently using IUD Proportion Currently married men age
Currently using injectables Proportion Currently married men age
Currently using condom Proportion Currently married men age
Currently using female sterilization Proportion Currently married men age
Currently using periodic abstinence Proportion Currently married men age
Want no more children Proportion Currently married men age
Want to delay birth at least 2 years Proportion Currently married men age
Ideal family size Mean Ever-married men
______________________________________________________________________________________________________________
1
Births occurring 1-59 months before interview
Appendix B * 225
Table B.2 Sampling errors - Total sample, Nepal 2001


Number of cases
Standard Design Relative Confidence limits
Value error Unweighted Weighted effect error
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE

WOMEN

Urban 0.096 0.007 8726 8726 2.229 0.073 0.082 0.110
Literate 0.355 0.012 8726 8726 2.410 0.035 0.331 0.380
No education 0.720 0.011 8726 8726 2.202 0.015 0.698 0.741
Secondary education 0.132 0.007 8726 8726 2.019 0.055 0.118 0.147
Net attendance ratio 0.730 0.015 6715 6715 2.360 0.021 0.700 0.761
Currently married 0.956 0.002 8726 8726 1.118 0.003 0.951 0.961
Married before age 20 0.808 0.005 8308 8290 1.321 0.006 0.798 0.818
Currently pregnant 0.071 0.003 10599 10626 1.257 0.044 0.064 0.077
Children ever born 2.708 0.043 10599 10626 1.368 0.016 2.621 2.795
Children surviving 2.293 0.034 10599 10626 1.309 0.015 2.224 2.361
Children ever born to women age 40-49 5.406 0.083 1895 1890 1.458 0.015 5.240 5.571
Total fertility rate (3 years) 4.108 0.111 na 30104 1.856 0.027 3.886 4.331
Know any contraceptive method 0.995 0.002 8324 8342 2.274 0.002 0.992 0.999
Ever used any contraceptive method 0.543 0.012 8324 8342 2.185 0.022 0.519 0.567
Currently using any contraceptive method 0.393 0.011 8324 8342 2.054 0.028 0.371 0.415
Currently using pill 0.016 0.002 8324 8342 1.581 0.135 0.012 0.021
Currently using IUD 0.004 0.001 8324 8342 1.188 0.205 0.002 0.006
Currently using injectables 0.084 0.005 8324 8342 1.530 0.055 0.075 0.094
Currently using condom 0.029 0.003 8324 8342 1.431 0.091 0.024 0.034
Currently using female sterilization 0.150 0.008 8324 8342 2.156 0.056 0.133 0.167
Currently using periodic abstinence 0.011 0.001 8324 8342 1.044 0.107 0.009 0.014
Using public sector source 0.794 0.012 3014 2952 1.679 0.016 0.769 0.819
Want no more children 0.443 0.009 8324 8342 1.676 0.021 0.425 0.461
Want to delay birth at least 2 years 0.166 0.004 8324 8342 1.081 0.027 0.157 0.175
Ideal family size 2.634 0.024 8577 8572 2.557 0.009 2.585 2.682
Perinatal mortality (0-4 years) 47.369 2.681 7089 7134 1.000 0.057 42.007 52.731
Neonatal mortality (0-4 years) 38.778 2.967 6998 7044 1.213 0.077 32.844 44.711
Postneonatal mortality (0-4 years) 25.626 2.220 7014 7059 1.156 0.087 21.185 30.066
Infant mortality (0-4 years) 64.403 3.885 7014 7059 1.267 0.060 56.633 72.174
Infant mortality (5-9 years) 90.029 4.183 7102 7070 1.149 0.046 81.664 98.395
Infant mortality (10-14 years) 107.157 6.072 6113 6025 1.374 0.057 95.013 119.302
Child mortality (0-4 years) 28.632 2.725 7085 7131 1.195 0.095 23.182 34.081
Under five mortality (0-4 years) 91.191 4.747 7101 7145 1.278 0.052 81.696 100.686
Mothers received tetanus injection for last birth 0.546 0.017 4731 4745 2.299 0.030 0.513 0.579
Mothers received medical assistance at delivery 0.129 0.008 6931 6978 1.746 0.061 0.113 0.144
Had diarrhea in the 2 weeks before survey 0.204 0.007 6416 6471 1.282 0.033 0.190 0.218
Treated with oral rehydration salts (ORS) 0.322 0.017 1285 1320 1.253 0.053 0.287 0.356
Taken to a health provider 0.212 0.015 1285 1320 1.267 0.071 0.182 0.242
Vaccination card seen 0.162 0.012 1299 1313 1.162 0.074 0.138 0.186
Received BCG vaccination 0.845 0.019 1299 1313 1.845 0.022 0.808 0.882
Received DPT vaccination (3 doses) 0.721 0.024 1299 1313 1.891 0.033 0.674 0.769
Received Polio vaccination (3 doses) 0.915 0.013 1299 1313 1.695 0.014 0.889 0.941
Received measles vaccination 0.706 0.022 1299 1313 1.774 0.032 0.661 0.751
Received vitamin A supplement 0.810 0.008 6261 6293 1.437 0.010 0.794 0.826
Height-for-age (-2 SD) 0.505 0.010 6337 6410 1.524 0.020 0.485 0.525
Weight-for-height (-2 SD) 0.096 0.006 6337 6410 1.468 0.058 0.085 0.108
Weight-for-age (-2 SD) 0.483 0.010 6337 6410 1.470 0.020 0.463 0.502
BMI <18.5 0.266 0.009 7821 7809 1.747 0.033 0.248 0.283
_________________________________________________________________________________________________________________________

MEN
_________________________________________________________________________________________________________________________

Literate 0.698 0.013 2261 2261 1.357 0.019 0.672 0.724
No education 0.377 0.013 2261 2261 1.323 0.036 0.350 0.404
Secondary education 0.327 0.015 2261 2261 1.473 0.044 0.298 0.356
Currently married 0.972 0.003 2261 2261 0.998 0.004 0.965 0.979
Knows any contraceptive method 0.996 0.003 2193 2198 2.243 0.003 0.990 1.002
Ever used any contraceptive method 0.690 0.015 2193 2198 1.474 0.021 0.661 0.719
Currently using any contraceptive method 0.487 0.014 2193 2198 1.333 0.029 0.459 0.516
Currently using pill 0.019 0.004 2193 2198 1.199 0.182 0.012 0.027
Currently using IUD 0.004 0.001 2193 2198 0.844 0.289 0.002 0.006
Currently using injectables 0.102 0.007 2193 2198 1.128 0.072 0.087 0.116
Currently using condom 0.063 0.006 2193 2198 1.124 0.092 0.052 0.075
Currently using female sterilization 0.171 0.011 2193 2198 1.390 0.065 0.148 0.193
Currently using periodic abstinence 0.020 0.003 2193 2198 1.092 0.162 0.014 0.027
Want no more children 0.476 0.014 2193 2198 1.300 0.029 0.448 0.504
Want to delay birth at least 2 years 0.195 0.008 2193 2198 0.960 0.042 0.179 0.211
Ideal family size 2.799 0.030 2213 2210 1.502 0.011 2.739 2.859

na = Not applicable
226 * Appendix B


Table B.3 Sampling errors - Urban sample, Nepal 2001


Number of cases
Standard Design Relative Confidence limits
Value error Unweighted Weighted effect error
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE
WOMEN


Urban 1.000 0.000 1154 841 -NaN 0.000 1.000 1.000
Literate 0.642 0.023 1154 841 1.649 0.036 0.596 0.689
No education 0.429 0.025 1154 841 1.721 0.058 0.379 0.479
Secondary education 0.379 0.020 1154 841 1.392 0.053 0.339 0.418
Net attendance ratio 0.887 0.016 774 573 1.217 0.018 0.855 0.919
Currently married 0.942 0.006 1154 841 0.931 0.007 0.929 0.955
Married before age 20 0.673 0.015 1246 913 1.258 0.022 0.644 0.702
Currently pregnant 0.043 0.005 1653 1162 1.002 0.119 0.033 0.054
Children ever born 2.099 0.091 1653 1162 1.012 0.043 1.917 2.281
Children surviving 1.872 0.071 1653 1162 0.906 0.038 1.729 2.015
Children ever born to women age 40-49 4.465 0.166 269 198 1.154 0.037 4.132 4.797
Total fertility rate (3 years) 2.076 0.101 na 3371 0.970 0.049 1.874 2.279
Know any contraceptive method 0.998 0.001 1088 792 1.025 0.001 0.995 1.001
Ever used any contraceptive method 0.773 0.021 1088 792 1.676 0.028 0.731 0.816
Currently using any contraceptive method 0.622 0.020 1088 792 1.344 0.032 0.583 0.662
Currently using pill 0.035 0.008 1088 792 1.389 0.222 0.019 0.050
Currently using IUD 0.016 0.004 1088 792 1.167 0.278 0.007 0.025
Currently using injectables 0.138 0.015 1088 792 1.394 0.106 0.109 0.167
Currently using condom 0.051 0.008 1088 792 1.211 0.158 0.035 0.068
Currently using female sterilization 0.218 0.028 1088 792 2.255 0.130 0.161 0.274
Currently using periodic abstinence 0.024 0.005 1088 792 1.053 0.205 0.014 0.033
Using public sector source 0.567 0.037 595 446 1.826 0.065 0.493 0.642
Want to delay birth at least 2 years 0.132 0.014 1088 792 1.374 0.107 0.104 0.161
Ideal family size 2.273 0.051 1136 827 2.356 0.022 2.171 2.374
Perinatal mortality (0-4 years) 36.635 8.462 651 458 1.051 0.231 19.710 53.560
Neonatal mortality (0-9) 36.561 6.183 1418 1010 1.040 0.169 24.195 48.927
Postneonatal mortality (0-9 years) 13.496 4.223 1419 1011 1.293 0.313 5.050 21.942
Infant mortality (0-9 years) 50.057 8.476 1419 1011 1.263 0.169 33.104 67.009
Child mortality (0-9 years) 16.696 3.361 1425 1014 1.004 0.201 9.974 23.418
Under five mortality (0-9 years) 65.917 9.752 1426 1015 1.272 0.148 46.413 85.421
Mothers received tetanus injection for last birth 0.812 0.024 466 332 1.315 0.030 0.763 0.860
Mothers received medical assistance at delivery 0.511 0.032 637 449 1.367 0.063 0.447 0.576
Had diarrhea in the 2 weeks before survey 0.166 0.021 608 431 1.291 0.124 0.125 0.207
Treated with oral rehydration salts (ORS) 0.456 0.062 107 71 1.142 0.136 0.332 0.580
Taken to a health provider 0.231 0.044 107 71 0.996 0.191 0.143 0.319
Vaccination card seen 0.175 0.047 121 87 1.348 0.270 0.081 0.269
Received BCG vaccination 0.884 0.036 121 87 1.219 0.041 0.812 0.955
Received DPT vaccination (3 doses) 0.782 0.047 121 87 1.244 0.061 0.687 0.876
Received Polio vaccination (3 doses) 0.954 0.034 121 87 1.774 0.036 0.885 1.022
Received measles vaccination 0.806 0.039 121 87 1.062 0.048 0.729 0.883
Received vitamin A supplement 0.753 0.019 594 422 0.926 0.025 0.716 0.791
Height-for-age (-2 SD) 0.367 0.024 602 426 1.119 0.064 0.320 0.414
Weight-for-height (-2 SD) 0.082 0.011 602 426 0.937 0.134 0.060 0.104
Weight-for-age (-2 SD) 0.330 0.022 602 426 1.060 0.067 0.286 0.374
BMI <18.5 0.167 0.012 1069 783 1.031 0.071 0.143 0.190
_________________________________________________________________________________________________________________________

MEN
_________________________________________________________________________________________________________________________

Literate 0.856 0.019 304 227 0.935 0.022 0.819 0.894
No education 0.207 0.033 304 227 1.440 0.162 0.140 0.274
Secondary education 0.575 0.045 304 227 1.573 0.078 0.486 0.664
Currently using any contraceptive method 0.660 0.030 298 223 1.091 0.045 0.600 0.720
Currently using pill 0.030 0.010 298 223 1.015 0.337 0.010 0.050
Currently using IUD 0.019 0.006 298 223 0.747 0.314 0.007 0.030
Currently using injectables 0.159 0.022 298 223 1.023 0.136 0.116 0.203
Currently using condom 0.090 0.019 298 223 1.135 0.210 0.052 0.127
Currently using female sterilization 0.193 0.030 298 223 1.327 0.158 0.132 0.253
Currently using periodic abstinence 0.027 0.010 298 223 1.095 0.384 0.006 0.047
Ideal family size 2.346 0.043 301 225 0.908 0.018 2.261 2.431

na = Not applicable
Appendix B * 227

Table B.4 Sampling errors - Rural sample, Nepal 2001


Number of cases
Standard Design Relative Confidence limits
Value error Unweighted Weighted effect error
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE
WOMEN

Literate 0.325 0.013 7572 7885 2.462 0.041 0.298 0.351
No education 0.751 0.011 7572 7885 2.234 0.015 0.728 0.773
Secondary education 0.106 0.008 7572 7885 2.166 0.072 0.091 0.121
Net attendance ratio 0.716 0.016 5941 6142 2.336 0.023 0.684 0.748
Currently married 0.957 0.003 7572 7885 1.129 0.003 0.952 0.963
Married before age 20 0.825 0.005 7091 7374 1.329 0.007 0.814 0.836
Currently pregnant 0.074 0.003 9069 9461 1.251 0.046 0.067 0.081
Children ever born 2.784 0.047 9069 9461 1.367 0.017 2.690 2.877
Children surviving 2.345 0.037 9069 9461 1.304 0.016 2.271 2.419
Children ever born to women age 40-49 5.523 0.091 1624 1690 1.485 0.016 5.342 5.705
Total fertility rate (3 years) 4.358 0.118 na 26760 1.802 0.027 4.121 4.595
Know any contraceptive method 0.995 0.002 7236 7550 2.270 0.002 0.991 0.999
Ever used any contraceptive method 0.519 0.013 7236 7550 2.196 0.025 0.493 0.545
Currently using any contraceptive method 0.369 0.012 7236 7550 2.086 0.032 0.346 0.393
Currently using pill 0.014 0.002 7236 7550 1.630 0.159 0.010 0.019
Currently using IUD 0.003 0.001 7236 7550 1.265 0.282 0.001 0.004
Currently using injectables 0.079 0.005 7236 7550 1.564 0.063 0.069 0.089
Currently using condom 0.027 0.003 7236 7550 1.466 0.104 0.021 0.032
Currently using female sterilization 0.143 0.009 7236 7550 2.125 0.061 0.125 0.160
Currently using periodic abstinence 0.010 0.001 7236 7550 1.058 0.124 0.007 0.012
Using public sector source 0.834 0.013 2419 2507 1.711 0.016 0.808 0.860
Want no more children 0.442 0.010 7236 7550 1.689 0.022 0.422 0.461
Want to delay birth at least 2 years 0.170 0.005 7236 7550 1.050 0.027 0.160 0.179
Ideal family size 2.672 0.026 7441 7746 2.585 0.010 2.619 2.725
Perinatal mortality (0-4 years) 48.105 2.804 6438 6676 0.985 0.058 42.496 53.713
Neonatal mortality (0-9) 48.525 2.500 12655 13080 1.180 0.052 43.524 53.525
Postneonatal mortality (0-9 years) 30.794 1.840 12681 13103 1.156 0.060 27.115 34.474
Infant mortality (0-9 years) 79.319 3.246 12681 13103 1.246 0.041 72.826 85.812
Child mortality (0-9 years) 35.406 2.722 12757 13183 1.480 0.077 29.962 40.850
Under five mortality (0-9 years) 111.917 4.248 12783 13206 1.375 0.038 103.421 120.412
Mothers received tetanus injection for last birth 0.526 0.018 4265 4414 2.300 0.034 0.491 0.561
Mothers received medical assistance at delivery 0.102 0.007 6294 6529 1.754 0.073 0.087 0.117
Had diarrhea in the 2 weeks before survey 0.207 0.007 5808 6040 1.263 0.034 0.193 0.221
Treated with oral rehydration salts (ORS) 0.314 0.018 1178 1249 1.245 0.056 0.278 0.349
Taken to a health provider 0.211 0.016 1178 1249 1.262 0.074 0.179 0.242
Vaccination card seen 0.161 0.012 1178 1226 1.138 0.077 0.136 0.186
Received BCG vaccination 0.842 0.020 1178 1226 1.841 0.023 0.803 0.881
Received DPT vaccination (3 doses) 0.717 0.025 1178 1226 1.889 0.035 0.667 0.767
Received Polio vaccination (3 doses) 0.912 0.014 1178 1226 1.668 0.015 0.885 0.940
Received measles vaccination 0.699 0.024 1178 1226 1.772 0.034 0.651 0.747
Received vitamin A supplement 0.814 0.008 5667 5870 1.458 0.010 0.797 0.831
Height-for-age (-2SD) 0.515 0.010 5735 5983 1.516 0.020 0.494 0.536
Weight-for-height (-2SD) 0.097 0.006 5735 5983 1.467 0.061 0.086 0.109
Weight-for-age (-2SD) 0.494 0.010 5735 5983 1.448 0.020 0.474 0.514
BMI <18.5 0.277 0.010 6752 7026 1.760 0.035 0.258 0.29
_________________________________________________________________________________________________________________________

MEN
_________________________________________________________________________________________________________________________

Literate 0.680 0.014 1957 2034 1.358 0.021 0.651 0.709
No education 0.396 0.014 1957 2034 1.299 0.036 0.367 0.424
Secondary education 0.299 0.015 1957 2034 1.474 0.051 0.269 0.330
Currently using any contraceptive method 0.468 0.016 1895 1975 1.354 0.033 0.437 0.499
Currently using pill 0.018 0.004 1895 1975 1.224 0.206 0.011 0.026
Currently using IUD 0.002 0.001 1895 1975 0.985 0.481 0.000 0.004
Currently using injectables 0.095 0.008 1895 1975 1.145 0.081 0.080 0.111
Currently using condom 0.061 0.006 1895 1975 1.124 0.102 0.048 0.073
Currently using female sterilization 0.168 0.012 1895 1975 1.391 0.071 0.144 0.192
Currently using periodic abstinence 0.020 0.003 1895 1975 1.090 0.177 0.013 0.027
Ideal family size 2.850 0.033 1912 1985 1.539 0.012 2.784 2.917

na = Not applicable





Appendix C * 229
DATA QUALITY TABLES APPENDIX




Table C.1 Household age distribution
Single-year age distribution of the de facto household population by sex (weighted), Nepal 2001
Males Females Males Females
Age Number Percent Number Percent Age Number Percent Number Percent
<1 658 3.2 694 3.0 37 182 0.9 207 0.9
1 640 3.1 677 2.9 38 185 0.9 227 1.0
2 625 3.0 686 2.9 39 201 1.0 228 1.0
3 719 3.4 686 2.9 40 215 1.0 224 1.0
4 681 3.3 683 2.9 41 158 0.8 220 0.9
5 677 3.2 661 2.8 42 167 0.8 231 1.0
6 681 3.3 675 2.9 43 134 0.6 201 0.9
7 735 3.5 679 2.9 44 172 0.8 163 0.7
8 661 3.2 667 2.9 45 203 1.0 215 0.9
9 629 3.0 607 2.6 46 172 0.8 193 0.8
10 686 3.3 603 2.6 47 141 0.7 166 0.7
11 601 2.9 551 2.4 48 144 0.7 170 0.7
12 674 3.2 644 2.8 49 133 0.6 104 0.4
13 521 2.5 552 2.4 50 164 0.8 163 0.7
14 536 2.6 508 2.2 51 147 0.7 208 0.9
15 441 2.1 464 2.0 52 121 0.6 161 0.7
16 410 2.0 514 2.2 53 114 0.5 161 0.7
17 382 1.8 527 2.3 54 103 0.5 161 0.7
18 402 1.9 495 2.1 55 134 0.6 153 0.7
19 299 1.4 423 1.8 56 118 0.6 158 0.7
20 314 1.5 423 1.8 57 140 0.7 111 0.5
21 295 1.4 435 1.9 58 114 0.5 89 0.4
22 288 1.4 445 1.9 59 74 0.4 78 0.3
23 232 1.1 347 1.5 60 111 0.5 124 0.5
24 242 1.2 369 1.6 61 134 0.6 125 0.5
25 292 1.4 420 1.8 62 110 0.5 104 0.4
26 223 1.1 391 1.7 63 91 0.4 72 0.3
27 227 1.1 327 1.4 64 81 0.4 81 0.3
28 278 1.3 317 1.4 65 115 0.6 104 0.4
29 245 1.2 317 1.4 66 64 0.3 68 0.3
30 260 1.2 357 1.5 67 107 0.5 107 0.5
31 220 1.1 321 1.4 68 76 0.4 65 0.3
32 247 1.2 324 1.4 69 61 0.3 48 0.2
33 238 1.1 284 1.2 70+ 524 2.5 491 2.1
34 190 0.9 231 1.0
35 273 1.3 332 1.4
Don't know/
missing

2

0.0

2

0.0

36 200 1.0 234 1.0
Total 20,833 100.0 23,253 100.0
Note: The de facto population includes all residents and nonresidents who stayed in the household
the night before interview.


C
230 * Appendix C

Table C.2.1 Age distribution of eligible and interviewed women
De facto household population of all women and ever-married women age 10-54,
percent distribution of interviewed women age 15-49, and percentage of eligible
women who were interviewed (weighted), by five-year age groups, Nepal 2001



Interviewed women
age 15-49


Age group

Household
population of
all women
age 10-54
Household
population
of ever-
married women
age 10-54 Number Percent
Percentage
of eligible
women
interviewed
(weighted)

10-14 2,858 15 na na na
15-19 2,423 952 939 10.7 98.6
20-24 2,019 1,716 1,697 19.3 98.9
25-29 1,771 1,698 1,664 19.0 98.0
30-34 1,517 1,483 1,463 16.7 98.6
35-39 1,228 1,204 1,182 13.5 98.1
40-44 1,039 1,030 1,013 11.5 98.4
45-49 849 836 818 9.3 97.9
50-54 854 849 na na na

15-49 10,846 8,918 8,775 100.0 98.4
Note: The de facto population includes all residents and nonresidents who stayed in
the household the night before the interview. Weights for both household population
of women and interviewed women are household weights. Age is based on the
household schedule.
na = Not applicable



Table C.2.2 Age distribution of eligible and interviewed men
De facto household population of all men and ever-married men age 10-64, the
percent distribution of interviewed men age 15-59, and the percentage of eligible
men who were interviewed (weighted), by five-year age groups, Nepal 2001



Interviewed men
age 15-59


Age group

Household
population
of all men
age 10-64
Household
population
of ever-
married men
age 10-64 Number Percent
Percentage
of eligible
men
interviewed
(weighted)

10-14 1,009 2 na na na
15-19 667 70 68 3.0 97.9
20-24 512 312 293 13.0 93.9
25-29 421 355 338 15.0 95.4
30-34 376 358 342 15.2 95.5
35-39 339 338 327 14.5 96.8
40-44 262 260 249 11.1 95.8
45-49 268 264 250 11.1 94.7
50-54 215 216 211 9.4 97.5
55-59 186 183 175 7.8 95.6
60-64 194 192 na na na

15-59 3,246 2,355 2,253 100.0 95.7
Note: The de facto population includes all residents and nonresidents who stayed in
the household the night before the interview. Weights for both household popula-
tion of men and interviewed men are household weights. Age is based on the
household schedule.
na = Not applicable





Appendix C * 231

Table C.3 Completeness of reporting
Percentage of observations missing information for selected demographic and health questions (weighted), Nepal 2001

Subject Reference group
Percentage
with missing
information
Number
of
cases
Birth date Births in the 15 years preceding the survey
Month only 0.07 20,077
Month and year 0.00 20,077

Age at death Deceased children born in the 15 years preceding the survey 0.54 2,381


Age/date at first union
1
Ever-married women age 15-49 0.06 8,726


Respondent's education Ever-married women age 15-49 0.00 8,726


Diarrhea in last 2 weeks Living children age 0-59 months 0.75 6,471


Anthropometry Living children age 0-59 months (from the household questionaire)

Height 2.55 6,692
Weight 1.76 6,692
Height or weight

2.55 6,692

1
Both year and age missing



232 * Appendix C

Table C.4 Births by calendar years
Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living (L), dead (D),
and total (T) children (weighted), Nepal 2001


Number of births
Percentage with complete
birth date
1


Sex ratio at birth
2


Calendar year ratio
3



Calendar year
(Nepali calendar) L D T L D T L D T L D T
2058 49 2 51 100.0 100.0 100.0 129.6 275.1 133.4 na na na
2057 1,259 73 1,333 100.0 100.0 100.0 92.9 78.2 92.1 na na na
2056 1,321 87 1,408 100.0 100.0 100.0 92.9 102.4 93.4 104.9 101.6 104.7
2055 1,259 97 1,357 100.0 100.0 100.0 93.6 146.6 96.6 95.4 91.8 95.1
2054 1,319 125 1,444 100.0 100.0 100.0 102.8 84.0 101.1 103.6 109.1 104.0
2053 1,288 132 1,420 99.9 100.0 99.9 103.9 111.1 104.6 97.6 104.6 98.2
2052 1,321 128 1,449 100.0 100.0 100.0 104.9 130.5 106.9 104.1 76.2 100.9
2051 1,250 203 1,453 99.9 100.0 99.9 100.0 104.9 100.6 96.8 127.8 100.2
2050 1,261 190 1,451 99.9 99.4 99.8 104.4 95.2 103.1 101.0 103.1 101.3
2049 1,248 165 1,413 99.9 100.0 100.0 104.6 88.0 102.5 105.5 86.9 102.9
2054-2058 5,208 384 5,593 100.0 100.0 100.0 95.8 100.3 96.1 na na na
2049-2053 6,367 818 7,185 99.9 99.9 99.9 103.6 103.4 103.5 na na na
2044-2048 5,242 996 6,238 99.9 99.7 99.9 110.4 92.7 107.4 na na na
2039-2043 3,828 911 4,740 99.9 99.7 99.9 102.5 104.7 102.9 na na na
<2039 3,714 1,305 5,019 99.9 99.5 99.8 104.2 113.0 106.4 na na na

All 24,360 4,414 28,774 99.9 99.7 99.9 103.2 103.5 103.2 na na na
Note: Since the new year in the Nepali calendar starts in mid-April, the cutoff for eligibility of births for questions in the health section was Baisakh
2052, which is roughly equivalent to April 1995
na = Not applicable
1
Both year and month of birth given
2
(B
m
/B
f
)x100, where B
m
and B
f
are the numbers of male and female births, respectively
3
[2B
x
/(B
x-1
+B
x+1
)]x100, where B
x
is the number of births in calendar year x






Appendix C * 233

Table C.5 Reporting of age at death in days
Distribution of reported deaths under one month of age
by age at death in days and the percentage of neonatal
deaths reported to occur at ages 0-6 days, for five-year
periods preceding the survey (weighted), Nepal 2001


Number of years
preceding the survey


Age
at death
(days) 0-4 5-9 10-14 15-19

Total
0-19
<1 92 124 131 101 447
1 22 38 37 30 128
2 9 20 18 15 62
3 20 35 24 15 94
4 15 17 8 13 52
5 15 15 19 14 62
6 9 10 16 13 48
7 12 14 12 9 46
8 8 17 15 13 53
9 7 5 14 7 33
10 3 9 13 1 26
11 10 7 8 10 35
12 5 13 6 5 29
13 1 5 6 6 18
14 4 5 5 8 22
15 4 14 13 11 42
16 6 5 4 5 19
17 1 3 5 3 12
18 1 4 10 0 15
19 0 3 0 3 6
20 3 12 2 2 19
21 1 2 0 1 4
22 5 9 6 0 20
23 2 5 1 3 10
24 1 1 1 0 2
25 4 2 1 3 10
26 1 1 1 1 4
27 2 2 1 1 6
28 2 2 3 0 7
29 1 0 2 1 3
30 0 0 0 2 2

Percent early
neonatal
1
68.9 64.8 66.7 67.7 66.8


1
#6 days / #30 days

234 * Appendix C

Table C.6 Reporting of age at death in months
Distribution of reported deaths under two years of age by
age at death in months and the percentage of infant
deaths reported to occur at age under one month, for five-
year periods preceding the survey, (weighted), Nepal
2001


Number of years
preceding the survey

Age
at death
(months) 0-4 5-9 10-14 15-19

Total
0-19
<1
a
264 399 378 296 1,337
1 38 49 49 45 181
2 19 26 21 17 83
3 26 27 21 24 97
4 10 22 22 13 67
5 9 13 23 15 60
6 11 15 29 20 75
7 8 7 16 12 44
8 13 12 13 14 51
9 11 14 18 20 63
10 9 18 22 12 61
11 10 19 22 28 79
12 8 26 26 38 98
13 11 10 9 3 33
14 6 5 11 9 31
15 2 9 11 3 25
16 2 2 6 2 12
17 4 3 3 6 16
18 10 23 34 33 100
19 7 1 7 2 16
20 1 3 3 3 10
21 0 0 2 1 3
22 0 0 4 4 8
23 1 5 1 9 17
Missing 4 4 5 7 20
1 Year 1 0 0 1 2

Percent neonatal
1
61.9 64.2 59.7 57.5 60.9

a
Includes deaths under 1 month reported in days
1
Under 1 month / under 1 year





Appendix D * 235
SURVEY STAFF APPENDIX


Technical and Administrative Staff

Project Director
Bharat Ban

Deputy Project Director
Anjushree Pradhan

Technical Advisor
Dr. Gokarna Regmi
Ajit Pradhan

Senior Technical Staff
Matrika Chapagain, Assistant Research Officer
Muneshor Shrestha, Research Assistant
Puspa Basnet, Research Assistant

Senior Data Processing Staff
Rajendra Lal Singh Dangol
Sarita Baidya

ORC Macro Staff
Dr. Pav Govindasamy, Country Manager
Anne R.Cross, Regional Coordinator
Dr. Alfredo Aliaga, Sampling Specialist
Guillermo Rojas, Deputy Chief of Data Processing
Livia Montana, GPS Specialist
Daniel Vadnais, Data Dissemination Coordinator
Dr. Sidney Moore, Editor
Celia Khan, Document Production
Kaye Mitchell, Document Production

Data Entry Operators
Usha Shrestha
Sahanshila Shrestha
Dipendra Mahat
Janani Magar
Kchhitiz Shrestha
Rajan Dangol
Sashindra Pradhan

File Editors
Deepa Shakya
Bikash Maharjan
D
236 * Appendix D
Administrative Staff
Anil Kumar Shrestha
Kishor Kumar Shrestha
Sunita Pradhan
Rajendra Kumar Shrestha

Word Processors
Sanu Raja Shakya
Geeta Amatya

Listing Staff

Ram Kumar Dhungel
Kiran Raj Dahal
Dupchen Lama
Jiwan Maharjan
Nirmal K. Shrestha
Ashok Shrestha
Shyam K. Purkutti
Sushi K. Joshi
Harendra Chauracia
Prakash Ghimire
Jagadish Adhikari
Achut Dahal
Nav R. Lamichhane
Surya Kanta Koirala
Narendra G.C.
Sagar Gyawali
Janak Chanda Ballan Chhetri
Som Deep Thapalia
Aalok Babu Prasai
Khadga Prasai
Badri Chapagai
Kumar Shrestha
Suresh Bhandari
Ram B. Thapa
Birendra Chaudhari
Rudra B. Shrestha
Raju Karki
Hari Kumar Shrestha
Arjun Adhikari
Jevan K. Prasai
Jitendra K. Kayastha
Netra Dangal
Dipendra K. Regmi
Bhola Khanal
Binit Ghimire
Birendra P. Ram
Mahendra Bajgai
Roshan Chapagai
Arjun Khatri
Damodar Adhikari
Arjun K. Pandey
Bijaya K. Yadra
Shyam Sundar Prasad
Raghu Nath P. Chaurcia
Ram Krishna Thapa
Dipesh Kr. Shah
Rabindra Udas
Mahendra Ghimire
Keshar Upreti
Bikesh Koirala
Radhyshyam Chaudhari
Dhama K.C.
Dambar Dutt Awesthi
Field Staff

Quality Control

Jevan K. Prasai
Mahendra Bajgai
Rabindra Udas
Appendix D * 237

Supervisors

Keshar Upreti
Sushil Joshi
Netra Dangal
Mithilesh P. Shah
Jitendra L. Kayastha
Birendra Chaudhari
Raju Karki
Dupchen Lama
Nar Raj Lamichhane
Suk Bahadur Gurung
Sher Singh Saud

Field Editors

Kalpana Shrestha
Prabha Khanal
Karuna Tuladhar
Baidehi Mallik
Sumitra Ranjit
Pramila Sharma
Kamala Shrestha
Malati Maskey
Lila Kumari Pandey
Iswara Prasai
Puma Kumari Shrestha

Interviewers

Prem Prasad Bastola
Geeta Adhikari
Bidya Devi Niroula
Muna Shrestha
Sabin Shrestha
Rabina Shrestha
Bhima Rijal
Sita Prasai
Krishna Prasad Basu
Sanu Maiya Maskey
Jamuna Kayastha
Radhika Tiwari
Shyam Sundar Prasad
Laxmi Bachhar
Kiran Chaudhari
Yasodha Baujada
Rudra B. Shrestha
Binita Baidya
Rubina Khatri
Mahesh P. Deo
Rani Malik
Sita Lama
Babita Bhattarai




Ram B. Thapa
Dibya Swara Mainali
Devi Maya Bogati
Saraswati Thapa
Gangu Basnet
Manju Sharma
Sabitri Giri
Rashila Shrestha
Narendra G.C.
Manju Shrestha
Dilli Maya Prasai
Laxmi Shrestha
Likhat Ram Paudel
Pabitra Yogi
Kumari Tamang
Iswori Panday
Dambar Dutt Awasthi
Srijana Adhikari
Sita Devi Adhikari
Laxmi Shova Shrestha
Maya Budhathoki
Roshan Chapagai





Appendix E * 239


QUESTIONNAIRES APPENDIX



E


1
JANUARY 15, 2001
NEPAL DEMOGRAPHIC AND HEALTH SURVEY 2001
HOUSEHOLD QUESTIONNAIRE


IDENTIFICATION


NAME AND CODE OF DISTRICT

NAME AND CODE OF VILLAGE/MUNICIPALITY


WARD NUMBER.........................................................................................................................................


CLUSTER NUMBER...................................................................................................................................


HOUSEHOLD NUMBER.............................................................................................................................


CITY=1/TOWN=2/COUNTRYSIDE=3.........................................................................................................


NAME OF HOUSEHOLD HEAD

NAME OF RESPONDENT

IS HOUSEHOLD SELECTED FOR MANS SURVEY (YES=1; NO=2).......................................................



























INTERVIEWER VISITS



1

2

3

FINAL VISIT

DATE





INTERVIEWERS NAME

RESULT**
































DAY

MONTH

YEAR 2200

INT.CODE

RESULT


NEXT VISIT: DATE







TIME







TOTAL NO.
OF VISITS





TOTAL
PERSONS IN
HOUSEHOLD





TOTAL
ELIGIBLE
WOMEN





TOTAL
ELIGIBLE
MEN





**RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT
HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER
(SPECIFY)

LINE NO. OF
RESP. TO
HOUSEHOLD
QUEST.





SUPERVISOR

FIELD EDITOR

OFFICE
EDITOR

KEYED BY

NAME

NAME

DATE





DATE















2
HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.


MARITAL STATUS LINE
NO.

USUAL RESIDENTS AND
VISITORS

RELATIONSHIP
TO HEAD OF
HOUSEHOLD

SEX

RESIDENCE

AGE

AGE 10 AND OVER

ELIGIBILITY



Please give me the names of
the persons who usually live in
your household and guests of
the household who stayed
here last night, starting with
the head of the household.










What is the
relationship of
(NAME) to the
head of the
household?*

Is
(NAME)
male or
female?

Does
(NAME)
usually
live
here?

Did
(NAME)
stay here
last
night?

How old is
(NAME)?

Has
(NAME)
ever
been
married?

IF YES

Has
(NAME)
started
living
with
his/her
spouse?

CIRCLE
LINE
NO. OF
ALL
WOMEN
AGE
15-49
WITH
YES IN
COL.8
AND
COL. 9.

CIRCLE
LINE NO.
OF MEN
AGE
15-59
WITH
YES IN
COL.8
AND COL.
9.

CIRCLE
LINE
NUMBER
OF ALL
CHILD-
REN
UNDER
AGE 6.

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)







M F

YES NO

YES NO

IN YEARS

YES NO

YES NO





01







1 2

1 2

1 2


1 2

1 2

01

01

01

02







1 2

1 2

1 2


1 2

1 2

02

02

02

03







1 2

1 2

1 2


1 2

1 2

03

03

03

04







1 2

1 2

1 2


1 2

1 2

04

04

04

05







1 2

1 2

1 2


1 2

1 2

05

05

05

06







1 2

1 2

1 2


1 2

1 2

06

06

06

07







1 2

1 2

1 2


1 2

1 2

07

07

07

08







1 2

1 2

1 2


1 2

1 2

08

08

08

09







1 2

1 2

1 2


1 2

1 2

09

09

09

10







1 2

1 2

1 2


1 2

1 2

09

09

09

11







1 2

1 2

1 2


1 2

1 2

09

09

09

12







1 2

1 2

1 2


1 2

1 2

10

10

10
* CODES FOR Q.3
01 = HEAD
02 = WIFE OR HUSBAND
03 = SON OR DAUGHTER
04 = SON-IN-LAW OR
DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT

07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = BROTHER-IN-LAW OR SISTER-IN-LAW
10 = NEPHEW, NIECE
11 = CO-WIFE
12 = OTHER RELATIVE
13 = ADOPTED/FOSTER/ STEPCHILD
14 = NOT RELATED
98 = DONT KNOW


3

LINE
NO.

EDUCATION



IF AGE 5 YEARS OR OLDER

IF AGE 5-24 YEARS

Has (NAME)
ever attended
school?

What is the highest
grade of school
(NAME) has
completed?**

Is (NAME)
currently
attending
school?

During the
current school
year, did (NAME)
attend school at
any time?

During the current
school year, what
grade is/was (NAME)
attending?**

During the
previous school
year, did
(NAME) attend
school at any
time?

During that school year,
what grade did (NAME)
attend?**



(13)

(14)

(15)

(16)

(17)

(18)

(19)



YES NO

GRADE

YES NO

YES NO

GRADE

YES NO

GRADE

01

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





02

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





03

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





04

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





05

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





06

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





07

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





08

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





09

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





10

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





11

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE





12

1 2
NEXT=
LINE





1 2
< GO TO
17

1 2
GO TO=
18





1 2
NEXT=
LINE




**CODES FOR Qs. 14, 17 AND 19
00 = LESS THAN GRADE 1
01 = GRADE 1
02 = GRADE 2
03 = GRADE 3
04 = GRADE 4

05 = GRADE 5
06 = GRADE 6
07 = GRADE 7
08 = GRADE 8
09 = GRADE 9
10 = COMPLETED SLC

11 = INTERMEDIATE 1
ST
YEAR/ 10+1
12 = INTERMEDIATE COMPLETE/ 10+2
13 = BACHELORS NOT COMPLETE
14 = BACHELORS COMPLETE/HIGHER
95 = NON-FORMAL EDUCATION
98 = DONT KNOW

TICK HERE IF CONTINUATION SHEET USED




Just to make sure that I have a complete listing:

1)

Are there any other persons such as small children or infants that we have not
listed?

YES